Provider Demographics
NPI:1124668447
Name:JACKSON, LAURIE (CADC)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:FORTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC
Mailing Address - Street 1:11400 SE 90TH AVE APT 1424
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-2626
Mailing Address - Country:US
Mailing Address - Phone:503-607-5791
Mailing Address - Fax:
Practice Address - Street 1:1122 NE 122ND AVE STE A102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2082
Practice Address - Country:US
Practice Address - Phone:855-237-9882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)