Provider Demographics
NPI:1215558937
Name:JACKSON, MICHELLE CHRISTINE (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CHRISTINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 73939
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0939
Mailing Address - Country:US
Mailing Address - Phone:253-720-4642
Mailing Address - Fax:
Practice Address - Street 1:9550 195TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-5969
Practice Address - Country:US
Practice Address - Phone:253-447-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61083974363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty