Provider Demographics
NPI:1750739694
Name:MACKLIN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MACKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 MAIN ST
Mailing Address - Street 2:#201
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1830
Mailing Address - Country:US
Mailing Address - Phone:503-655-1029
Mailing Address - Fax:
Practice Address - Street 1:511 MAIN ST
Practice Address - Street 2:#201
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1830
Practice Address - Country:US
Practice Address - Phone:503-655-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR4284101YM0800X
OR17-03-08101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health