Provider Demographics
NPI:1013034255
Name:JACKSON, DANETTE P (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 CUSTER ROAD W.
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499
Mailing Address - Country:US
Mailing Address - Phone:253-476-7327
Mailing Address - Fax:253-476-0585
Practice Address - Street 1:7525 CUSTER ROAD W.
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-476-7327
Practice Address - Fax:253-476-0585
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00001210231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7127665Medicaid
WA0196115OtherLABOR AND INDUSTRIES
WA9058553Medicaid
WA7127665Medicaid
WA0196115OtherLABOR AND INDUSTRIES