Provider Demographics
NPI:1598054132
Name:JACKSON, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:#411
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3033
Mailing Address - Country:US
Mailing Address - Phone:503-413-5702
Mailing Address - Fax:503-413-6499
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:#411
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3033
Practice Address - Country:US
Practice Address - Phone:503-413-5702
Practice Address - Fax:503-413-6499
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD170303207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine