Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H3677 | OR |
NPI | 1003983362 |
---|---|
Provider Name | Kathleen Marie Jackson |
First Address | Aloha, OR 97007-2162 |
Second Address | Beaverton, OR 97006-4443 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 08/07/2007 |