Provider Demographics
NPI:1811567589
Name:AMBERWOOD, JACKLYN (LCSW)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:AMBERWOOD
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 1:4722 SW BUDDINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7315
Mailing Address - Country:US
Mailing Address - Phone:503-956-0087
Mailing Address - Fax:
Practice Address - Street 1:1815 SW MARLOW AVE STE 218
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5187
Practice Address - Country:US
Practice Address - Phone:503-444-4862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical