Provider Demographics
NPI:1174923627
Name:JACKSON, ANNE MARTHA (RN, MN, CNS)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:MARTHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, MN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13175 SE KUEHN RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4730
Mailing Address - Country:US
Mailing Address - Phone:503-970-4201
Mailing Address - Fax:
Practice Address - Street 1:13175 SE KUEHN RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4730
Practice Address - Country:US
Practice Address - Phone:503-970-4201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00110808163W00000X
OR099006034RN163W00000X
OR200670017CNS364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163W00000XNursing Service ProvidersRegistered Nurse