Provider Demographics
NPI:1194178830
Name:BLACKWELL, JACQUELYN TAYLOR (MS)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:TAYLOR
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:TAYLOR
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5285 SW MEADOWS RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035
Mailing Address - Country:US
Mailing Address - Phone:503-726-5216
Mailing Address - Fax:503-726-5218
Practice Address - Street 1:5285 SW MEADOWS RD
Practice Address - Street 2:SUITE 170
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035
Practice Address - Country:US
Practice Address - Phone:503-726-5216
Practice Address - Fax:503-726-5218
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-02-02101YA0400X
ORC4984101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500715046Medicaid