Provider Demographics
NPI:1790276921
Name:JACKSON, HEATHER ANN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21370 SW LANGER FARMS PKWY
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9137
Mailing Address - Country:US
Mailing Address - Phone:503-625-6247
Mailing Address - Fax:
Practice Address - Street 1:21370 SW LANGER FARMS PKWY STE 138
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9140
Practice Address - Country:US
Practice Address - Phone:503-625-6247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist