Provider Demographics
NPI:1083119499
Name:JACKSON, CAROLINE VANDIVER (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:VANDIVER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 SAND POINT WAY NE, O.C. 7.830
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105
Mailing Address - Country:US
Mailing Address - Phone:206-987-2525
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE, O.C. 7.830
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-987-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAML60864284208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program