Provider Demographics
NPI:1285627547
Name:JACKSON, FREDRIC NEVEN (MD PS)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:NEVEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16259 SYLVESTER RD SW STE 404
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3059
Mailing Address - Country:US
Mailing Address - Phone:206-241-1818
Mailing Address - Fax:206-244-3991
Practice Address - Street 1:16259 SYLVESTER RD SW
Practice Address - Street 2:STE 404
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3049
Practice Address - Country:US
Practice Address - Phone:206-241-1818
Practice Address - Fax:206-244-3991
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019031207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110046684OtherRR MEDICARE
WA1783901Medicaid
WA110046684OtherRR MEDICARE
G000102480Medicare PIN
WA000102480Medicare ID - Type Unspecified