Provider Demographics
NPI:1043324049
Name:JACKY, PETER (PHD, FACMG)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:JACKY
Suffix:
Gender:M
Credentials:PHD, FACMG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 NW BARNES RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-1012
Mailing Address - Country:US
Mailing Address - Phone:503-223-8985
Mailing Address - Fax:
Practice Address - Street 1:13705 NE AIRPORT WAY
Practice Address - Street 2:SUITE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1048
Practice Address - Country:US
Practice Address - Phone:503-258-6721
Practice Address - Fax:503-258-6732
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Not Answered246ZG1000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGeneticist, Medical (PhD)