Provider Demographics
NPI:1043239429
Name:JACKSON, MICHAEL REID (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:REID
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5350 ORCHARD ST W
Mailing Address - Street 2:SUITE 202
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-4817
Mailing Address - Country:US
Mailing Address - Phone:253-472-4444
Mailing Address - Fax:253-401-4360
Practice Address - Street 1:5350 ORCHARD ST W
Practice Address - Street 2:SUITE 202
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-4817
Practice Address - Country:US
Practice Address - Phone:253-472-4444
Practice Address - Fax:253-301-4360
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0019523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1077510Medicaid
WAAB13323Medicare ID - Type Unspecified
WAA05983Medicare UPIN