Provider Demographics
NPI:1568807410
Name:JACKSON, ALYCIA WAI LIN (MD)
Entity Type:Individual
Prefix:MRS
First Name:ALYCIA
Middle Name:WAI LIN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:ALYCIA
Other - Middle Name:WAI LIN
Other - Last Name:YEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9290 SE SUNNYBROOK BLVD
Mailing Address - Street 2:#120
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6899
Mailing Address - Country:US
Mailing Address - Phone:503-215-2110
Mailing Address - Fax:503-215-2115
Practice Address - Street 1:9290 SE SUNNYBROOK BLVD
Practice Address - Street 2:#120
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6899
Practice Address - Country:US
Practice Address - Phone:503-215-2110
Practice Address - Fax:503-215-2115
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD180196207Q00000X
CAA133720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine