Provider Demographics
NPI:1194866707
Name:JACKSON, COREY JAI (MA)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:JAI
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 COUNTRY CLUB RD STE 222
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2238
Mailing Address - Country:US
Mailing Address - Phone:541-686-6000
Mailing Address - Fax:
Practice Address - Street 1:921 COUNTRY CLUB RD STE 222
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2238
Practice Address - Country:US
Practice Address - Phone:541-686-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4737101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional