Provider Demographics
NPI:1538997366
Name:JACKSON, TYLER ALANA
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:ALANA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E HISTORIC COLUMBIA RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-2006
Mailing Address - Country:US
Mailing Address - Phone:214-934-4344
Mailing Address - Fax:
Practice Address - Street 1:121 E HISTORIC COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-2006
Practice Address - Country:US
Practice Address - Phone:971-293-9237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILJ25080199625171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator