Provider Demographics
NPI:1871183202
Name:JACKSON, KAREN GAIL
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:GAIL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 BALD EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-1871
Mailing Address - Country:US
Mailing Address - Phone:541-979-8683
Mailing Address - Fax:
Practice Address - Street 1:377 NW JASPER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1279
Practice Address - Country:US
Practice Address - Phone:503-623-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8845225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant