Provider Demographics
NPI:1669429700
Name:JACKSON, CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:STE 316
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-256-1575
Mailing Address - Fax:503-253-9848
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:STE 316
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-256-1575
Practice Address - Fax:503-253-9848
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019884208600000X
ORMD166621208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8539900Medicaid
WAAB05032Medicare PIN