NPIMap

Individual provider Active NPI

Shannon E Jackson, MD

  • Internal Medicine Physician
  • Portland, OR
National Provider Identifier
1558301168
Registry record updated Mar 18, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
MD25874 Issued in OR
Practice address
4805 NE Glisan St
Portland, OR 97213-2933
Phone
(503) 215-2393
NPI assigned
Jun 8, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 18, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X MD25874 OR Primary

Addresses

Primary practice location

4805 NE Glisan St
Portland, OR 97213-2933

Mailing address

PO Box 3158
Portland, OR 97208-3158

Other identifiers 1

IdentifierTypeStateIssuer
028116MedicaidOR

Electronic endpoints 3

TypeEndpointUseAffiliation
Direct Messaging Address sjackson110052@oc.providencedirect.org
Direct Messaging Address sjackson110052@oc.providencedirect.org
Direct Messaging Address sjackson110052@oc.providencedirect.org

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20070305000236 OR Practitioner - Internal Medicine 0446352827 Reassigns benefits to 8 organizations

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Loma Linda University School of Medicine, 2003
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Providence Health and Services MtGroup PAC ID 6608786306, 358 clinicians

Practice addresses (Care Compare)

Beaverton, OR 97005

Portland, OR 97225

10330 SE 32ND Ave
Suite 205
Milwaukie, OR 97222-6594
Phone (503) 513-8950

1224 NW 100TH Ter
Portland, OR 97229-1072

7030 SW Gable Pkwy
Portland, OR 97225-2618

9205 SW Barnes Rd
Portland, OR 97225-6603

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Health & Services Oregon Current Accepting new patients
Providence Health & Services Oregon CurrentSince Jan 1, 2007 Accepting new patients
Providence Health & Services Washington Internal Medicine CurrentSince Sep 1, 2022 Accepting new patients
Providence Health & Services Oregon Internal Medicine Current Accepting new patients
Providence Health & Services Washington CurrentSince Aug 1, 2022 Accepting new patients
Providence Health & Services - Oregon CurrentSince Jan 1, 2007 Accepting new patients
Providence Health & Services - Oregon CurrentSince Nov 1, 2021 Accepting new patients
Providence Health & Services- Washington CurrentSince Feb 8, 2023 Accepting new patients
Providence Health & Services - Washington Internal Medicine CurrentSince Sep 1, 2022 Accepting new patients
Providence Health & Services - Oregon Internal Medicine CurrentSince Nov 1, 2021 Accepting new patients
Providence Health & Services Mt Internal Medicine CurrentSince Sep 1, 2022 Accepting new patients
Providence Health & Services- Washington CurrentSince Oct 18, 2022 Accepting new patients
Providence Health & Services - Oregon Internal Medicine Past Accepting new patients
Mid-Columbia Medical Center Past Accepting new patients
Providence Health & Services - Oregon Internal Medicine Past Accepting new patients

Locations

200 S Hazel Dell Way
Canby, OR 97013
Phone (203) 263-9500

9290 SE Sunnybrook Blvd
Ste 210
Clackamas, OR 97015
Phone (503) 216-7960

810 12th St
Hood River, OR 97031
Phone (541) 386-3911

940 Royal Ave
Unit 350
Medford, OR 97504
Phone (541) 732-7460

1111 Crater Lake Ave
Medford, OR 97504
Phone (541) 732-5250

1321 NE 99th Ave
Ste 100
Portland, OR 97220
Phone (503) 215-4050

5050 NE Hoyt St
Ste 240
Portland, OR 97213
Phone (503) 215-6480

4805 NE Glisan St
Portland, OR 97213
Phone (503) 215-1111

1321 NE 99th Ave
Ste 200
Portland, OR 97220
Phone (503) 215-4250

9205 SW Barnes Rd
Portland, OR 97225
Phone (503) 216-1234

9135 SW Barnes Rd
Ste 763
Portland, OR 97225
Phone (503) 216-6560

5050 NE Hoyt St
Ste 540
Portland, OR 97213
Phone (503) 215-6600

6350 NE Halsey St
Portland, OR 97213
Phone (503) 215-0750

4104 SE 82nd Ave
Ste 250
Portland, OR 97266
Phone (503) 215-9850

9205 SW Barnes Rd
Ste 2800
Portland, OR 97225
Phone (503) 216-2621

5050 NE Hoyt St
Ste 454
Portland, OR 97213
Phone (503) 215-6405

10330 SE 32nd Ave
Ste 205
Portland, OR 97222
Phone (503) 513-8950

12442 SW Scholls Ferry Rd
Ste 100
Tigard, OR 97223
Phone (503) 215-9900

Organizations & group practices 15

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

View all 15

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149724800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1616025600000",
    "number": "1558301168",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4805 NE GLISAN ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972132933",
            "telephone_number": "503-215-2393"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "SHANNON",
        "middle_name": "E",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-08",
        "last_updated": "2021-03-18",
        "certification_date": "2021-03-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "OR",
            "license": "MD25874",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "028116",
            "state": "OR"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "sjackson110052@oc.providencedirect.org",
            "affiliation": "N",
            "address_1": "4805 NE Glisan St",
            "city": "Portland",
            "state": "OR",
            "country_code": "US",
            "postal_code": "972132933",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "sjackson110052@oc.providencedirect.org",
            "affiliation": "N",
            "address_1": "6350 NE Halsey St",
            "city": "Portland",
            "state": "OR",
            "country_code": "US",
            "postal_code": "972134720",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "sjackson110052@oc.providencedirect.org",
            "affiliation": "N",
            "address_1": "9135 SW Barnes Rd Ste 763",
            "city": "Portland",
            "state": "OR",
            "country_code": "US",
            "postal_code": "972256777",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

Verify at the official NPI Registry.