Provider Demographics
NPI:1780390864
Name:THE JACKSON MACY CLINIC LLC
Entity type:Organization
Organization Name:THE JACKSON MACY CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:WHCNP-BC, CNM
Authorized Official - Phone:503-724-8188
Mailing Address - Street 1:19365 SW 65TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9196
Mailing Address - Country:US
Mailing Address - Phone:503-454-0018
Mailing Address - Fax:503-848-3471
Practice Address - Street 1:19365 SW 65TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9196
Practice Address - Country:US
Practice Address - Phone:503-454-0018
Practice Address - Fax:503-848-3471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty