Provider Demographics
NPI:1285992628
Name:JACKSON, RACHAEL ALEXIS (MS, MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:RACHAEL
Middle Name:ALEXIS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 SW 4TH AVE STE 520
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1825
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:8401 NE HALSEY ST STE 107
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-5670
Practice Address - Country:US
Practice Address - Phone:503-998-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ORL10943101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical