Provider Demographics
NPI:1083442164
Name:VAN, JACKSON (DMD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10952 SE LENORE ST
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-8789
Mailing Address - Country:US
Mailing Address - Phone:503-475-9235
Mailing Address - Fax:
Practice Address - Street 1:20140 MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2604
Practice Address - Country:US
Practice Address - Phone:971-404-1374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD120501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice