Provider Demographics
NPI:1386183416
Name:JACKSON, JACKLENE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JACKLENE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACKLENE
Other - Middle Name:
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX C
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761-3001
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:
Practice Address - Street 1:1270 KOT-NUM RD.
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201242738RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health