Provider Demographics
NPI:1114575016
Name:JACKSON, JUDITH LYNN
Entity Type:Individual
Prefix:MISS
First Name:JUDITH
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 N CHERRY ST APT C105
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-5009
Mailing Address - Country:US
Mailing Address - Phone:509-413-2792
Mailing Address - Fax:
Practice Address - Street 1:2820 N CHERRY ST APT C105
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-5009
Practice Address - Country:US
Practice Address - Phone:509-413-2792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider