Provider Demographics
NPI:1417096082
Name:JACKSON, LACEY (LMP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14654
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98511-4654
Mailing Address - Country:US
Mailing Address - Phone:360-570-2273
Mailing Address - Fax:
Practice Address - Street 1:712 TROSPER RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6934
Practice Address - Country:US
Practice Address - Phone:360-570-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013081174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist