Provider Demographics
NPI:1114990587
Name:ERICKSON, JAY C (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:C
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 S J ST FL 5
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4930
Mailing Address - Country:US
Mailing Address - Phone:253-274-7505
Mailing Address - Fax:253-274-7947
Practice Address - Street 1:1608 S J ST FL 5
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4930
Practice Address - Country:US
Practice Address - Phone:253-274-7505
Practice Address - Fax:253-274-7947
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052312A2084N0400X
WAMD608230492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2116964Medicaid
IN01052312AOtherMEDICAL LICENSE
WABE8985193OtherDEA NUMBER