Provider Demographics
NPI:1851546329
Name:JACKSON, LYDIA BURR (PA)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:BURR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 SE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4218
Mailing Address - Country:US
Mailing Address - Phone:503-601-7400
Mailing Address - Fax:503-601-7311
Practice Address - Street 1:8844 BENSON RD
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-9787
Practice Address - Country:US
Practice Address - Phone:360-318-0260
Practice Address - Fax:360-318-0261
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61495995363A00000X
ORPA01417363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical