Provider Demographics
NPI:1033214291
Name:JACKSON, MICHELE D (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27005 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-9250
Mailing Address - Country:US
Mailing Address - Phone:253-839-9280
Mailing Address - Fax:253-839-9375
Practice Address - Street 1:27005 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-9250
Practice Address - Country:US
Practice Address - Phone:253-839-9280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00303497OtherRAILROAD MEDICARE
WA0296927OtherL & I
WA8413668Medicaid
WA0197668OtherDEPT OF LABOR & INDUSTRY
WA8854612Medicare ID - Type Unspecified
WAG8910370Medicare PIN