Provider Demographics
NPI:1477769651
Name:JACKSON, DEBRA LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1892 WILLAMETTE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3383
Mailing Address - Country:US
Mailing Address - Phone:541-465-1885
Mailing Address - Fax:541-344-4620
Practice Address - Street 1:1892 WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4404
Practice Address - Country:US
Practice Address - Phone:541-465-1885
Practice Address - Fax:541-344-4620
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1221103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1221OtherSTATE LICENSE NUMBER
OR71-0900914OtherEIN
OR71-0900914OtherEIN