Provider Demographics
NPI:1073501177
Name:JACKSON, DONALD L (PA C)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:L
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-944-9644
Practice Address - Street 1:840 S MEYERS ST
Practice Address - Street 2:
Practice Address - City:KETTLE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99141
Practice Address - Country:US
Practice Address - Phone:509-738-6607
Practice Address - Fax:509-738-4180
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8118986Medicaid
127584OtherL & I
8935341OtherL & I CRIME VICTIMS
WAGAB36943Medicare ID - Type Unspecified
WA8118986Medicaid