Provider Demographics
NPI:1659083129
Name:JACKSON, KELLY ROSE (WHCNP, CNM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:WHCNP, CNM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ROSE
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHCNP, CNM
Mailing Address - Street 1:22400 SALAMO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-8269
Mailing Address - Country:US
Mailing Address - Phone:503-723-7234
Mailing Address - Fax:503-650-4464
Practice Address - Street 1:22400 SALAMO RD STE 201
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-8269
Practice Address - Country:US
Practice Address - Phone:503-723-7234
Practice Address - Fax:503-650-4464
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10002453363LW0102X
OR10005243367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty