Provider Demographics
NPI:1093867723
Name:JACKSON, JOHN THOMAS (LMP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMP
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 98530
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-0530
Mailing Address - Country:US
Mailing Address - Phone:206-592-1423
Mailing Address - Fax:206-592-1428
Practice Address - Street 1:22007 MARINE VIEW DR S
Practice Address - Street 2:SUITE 104
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6259
Practice Address - Country:US
Practice Address - Phone:206-592-1423
Practice Address - Fax:206-592-1428
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005314174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist