Provider Demographics
NPI:1154724193
Name:JACKIW, VIDHRA MAUREEN (LAC)
Entity type:Individual
Prefix:
First Name:VIDHRA
Middle Name:MAUREEN
Last Name:JACKIW
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 SE 6TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3502
Mailing Address - Country:US
Mailing Address - Phone:971-350-8508
Mailing Address - Fax:971-275-1552
Practice Address - Street 1:1623 SE 6TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3502
Practice Address - Country:US
Practice Address - Phone:971-350-8508
Practice Address - Fax:971-275-1552
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-05
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC169857171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500773023Medicaid