Provider Demographics
NPI:1144266438
Name:JACKSON, KATHI LU (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHI
Middle Name:LU
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KATHI
Other - Middle Name:L
Other - Last Name:MORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2722 COLBY AVE
Mailing Address - Street 2:STE 518
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-6600
Mailing Address - Country:US
Mailing Address - Phone:425-374-7225
Mailing Address - Fax:425-740-3182
Practice Address - Street 1:2722 COLBY AVE
Practice Address - Street 2:STE 518
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-6600
Practice Address - Country:US
Practice Address - Phone:425-374-7225
Practice Address - Fax:425-740-3182
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1483103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q56101Medicare UPIN
OR027927Medicaid
133154Medicare ID - Type Unspecified