Provider Demographics
NPI:1902927783
Name:JACKSON, CHRISTINE WILKES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:WILKES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 SE MORRISON ST
Mailing Address - Street 2:SUITE 650
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2327
Mailing Address - Country:US
Mailing Address - Phone:503-234-2098
Mailing Address - Fax:
Practice Address - Street 1:516 SE MORRISON ST
Practice Address - Street 2:SUITE 650
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2327
Practice Address - Country:US
Practice Address - Phone:503-234-2098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1641103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical