Provider Demographics
NPI:1326186271
Name:JACKSON, LASHAUNDA LOUISE
Entity Type:Individual
Prefix:
First Name:LASHAUNDA
Middle Name:LOUISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12942 SE MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4151
Mailing Address - Country:US
Mailing Address - Phone:503-754-3088
Mailing Address - Fax:
Practice Address - Street 1:509 NE ALBERTA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3976
Practice Address - Country:US
Practice Address - Phone:503-249-7767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No171M00000XOther Service ProvidersCase Manager/Care Coordinator