Provider Demographics
NPI:1114990462
Name:JACKA, THOMAS E (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:JACKA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S 320TH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4691
Mailing Address - Country:US
Mailing Address - Phone:253-946-3575
Mailing Address - Fax:
Practice Address - Street 1:700 S 320TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4691
Practice Address - Country:US
Practice Address - Phone:253-946-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA56571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice