Provider Demographics
NPI:1417435967
Name:JACKSON, JOHN L (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 164TH ST SE APT C301
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1702
Mailing Address - Country:US
Mailing Address - Phone:904-476-0124
Mailing Address - Fax:
Practice Address - Street 1:18323 98TH AVE NE STE 1
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3358
Practice Address - Country:US
Practice Address - Phone:425-371-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60863261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist