Provider Demographics
NPI:1013939453
Name:JACKSON, STUART MARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STUART
Middle Name:MARK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5331 SW MACADAM AVE
Mailing Address - Street 2:SUITE 363
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6104
Mailing Address - Country:US
Mailing Address - Phone:503-803-1250
Mailing Address - Fax:
Practice Address - Street 1:5331 SW MACADAM AVE
Practice Address - Street 2:SUITE 363
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6104
Practice Address - Country:US
Practice Address - Phone:503-803-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL37691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical