Provider Demographics
NPI:1457101024
Name:LIN, JACKY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:
Last Name:LIN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 NW HOYT ST APT 807
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2284
Mailing Address - Country:US
Mailing Address - Phone:608-346-6858
Mailing Address - Fax:
Practice Address - Street 1:1821 NE 33RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5113
Practice Address - Country:US
Practice Address - Phone:503-535-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0019953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist