Provider Demographics
NPI:1134565138
Name:BAIN, JACKIE LYNN (BS)
Entity type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYNN
Last Name:BAIN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYNN
Other - Last Name:HOLLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:2521 SE 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1150
Mailing Address - Country:US
Mailing Address - Phone:503-726-3706
Mailing Address - Fax:
Practice Address - Street 1:2521 SE 74TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1150
Practice Address - Country:US
Practice Address - Phone:503-726-3706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health