Provider Demographics
NPI:1790897437
Name:ULBRIGHT, SUSAN JACKSON (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JACKSON
Last Name:ULBRIGHT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 SW BASELINE ST
Mailing Address - Street 2:SUITE B 240
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-3835
Mailing Address - Country:US
Mailing Address - Phone:503-789-4482
Mailing Address - Fax:503-846-9515
Practice Address - Street 1:1049 SW BASELINE ST
Practice Address - Street 2:SUITE B 240
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-3835
Practice Address - Country:US
Practice Address - Phone:503-789-4482
Practice Address - Fax:503-846-9515
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORV648P-2973OtherSALEM VETERANS CENTER
ORPIN 131871Medicare ID - Type UnspecifiedMEDICARE PART B