Provider Demographics
NPI:1780331967
Name:RADCLIFFE, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:RADCLIFFE
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 1:912 NE KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5629
Mailing Address - Country:US
Mailing Address - Phone:503-912-5502
Mailing Address - Fax:
Practice Address - Street 1:7935A SE RAYMOND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4261
Practice Address - Country:US
Practice Address - Phone:951-551-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF2433504106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician