Provider Demographics
NPI:1194356618
Name:JACKSON, DEFORREST KWESI (CADC-1)
Entity Type:Individual
Prefix:
First Name:DEFORREST
Middle Name:KWESI
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 SE 90TH AVE APT 1424
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-2626
Mailing Address - Country:US
Mailing Address - Phone:503-432-7975
Mailing Address - Fax:
Practice Address - Street 1:12670 NW BARNES RD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-9001
Practice Address - Country:US
Practice Address - Phone:971-232-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-20-047101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)