Provider Demographics
NPI:1629471289
Name:JACKSON, MICHELLE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HALLISEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7905 SW LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-3370
Mailing Address - Country:US
Mailing Address - Phone:503-318-6286
Mailing Address - Fax:
Practice Address - Street 1:3993 CHERRY AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4861
Practice Address - Country:US
Practice Address - Phone:503-926-9322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1034297225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics