Provider Demographics
NPI:1083703391
Name:JACKSON, CONSTANCE JANENE (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:JANENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3439 NE SANDY BLVD
Mailing Address - Street 2:PMB 375
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-284-8841
Mailing Address - Fax:503-282-3302
Practice Address - Street 1:4800 SW MACADAM AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3925
Practice Address - Country:US
Practice Address - Phone:503-297-6656
Practice Address - Fax:503-297-5779
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2011-11-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD184092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry