Provider Demographics
NPI:1801255328
Name:YC SBHC
Entity type:Organization
Organization Name:YC SBHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACZKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-852-6960
Mailing Address - Street 1:PO BOX 544
Mailing Address - Street 2:
Mailing Address - City:YAMHILL
Mailing Address - State:OR
Mailing Address - Zip Code:97148-0544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 LARCH PL
Practice Address - Street 2:
Practice Address - City:YAMHILL
Practice Address - State:OR
Practice Address - Zip Code:97148-2007
Practice Address - Country:US
Practice Address - Phone:503-852-6960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250196NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652931Medicaid
1487647954OtherNPI