Provider Demographics
NPI:1942401351
Name:JACKSON, DONNA LIANNE (PT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LIANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11546 SW LAKEVIEW TER
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-7859
Mailing Address - Country:US
Mailing Address - Phone:503-524-4249
Mailing Address - Fax:
Practice Address - Street 1:4035 MERCANTILE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2546
Practice Address - Country:US
Practice Address - Phone:503-216-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist