Provider Demographics
NPI:1518000140
Name:JACKSON, ANDREA (LAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 SE 159TH PL
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4406
Mailing Address - Country:US
Mailing Address - Phone:503-545-2393
Mailing Address - Fax:
Practice Address - Street 1:33 NE KELLY AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7539
Practice Address - Country:US
Practice Address - Phone:503-545-2393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01036171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist