Provider Demographics
NPI:1053324186
Name:JACKSON, TOMMY LAMAR (PA-C)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:LAMAR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 YAKIMA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5304
Mailing Address - Country:US
Mailing Address - Phone:253-382-8540
Mailing Address - Fax:
Practice Address - Street 1:1802 YAKIMA AVE STE 204
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5304
Practice Address - Country:US
Practice Address - Phone:253-382-8540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60988499363AS0400X, 363A00000X
GA004173363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2150243Medicaid
GA97WCFFHMedicare ID - Type Unspecified