Provider Demographics
NPI:1720338965
Name:CRAFT, JACKIE SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:SUE
Last Name:CRAFT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:SUE
Other - Last Name:SCHOBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4531 SE BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1675
Mailing Address - Country:US
Mailing Address - Phone:503-215-6556
Mailing Address - Fax:
Practice Address - Street 1:4531 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1675
Practice Address - Country:US
Practice Address - Phone:503-215-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200030009LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse