Provider Demographics
NPI:1346228376
Name:JACKSON, MICHELE ALLYN (CNM, ARNP)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:ALLYN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNM, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7622 66TH PL NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-6593
Mailing Address - Country:US
Mailing Address - Phone:360-658-8791
Mailing Address - Fax:
Practice Address - Street 1:12303 NE 130TH LN
Practice Address - Street 2:SUITE 500
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3099
Practice Address - Country:US
Practice Address - Phone:425-899-4455
Practice Address - Fax:425-899-4434
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006675363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MQ0143850OtherDEA