Provider Demographics
NPI:1245663608
Name:DAVIDSON, JACK LEMUEL
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:LEMUEL
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 N ARLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7212
Mailing Address - Country:US
Mailing Address - Phone:503-432-3975
Mailing Address - Fax:503-467-0582
Practice Address - Street 1:707 NE COUCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2922
Practice Address - Country:US
Practice Address - Phone:503-542-4603
Practice Address - Fax:503-233-6093
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker