Provider Demographics
NPI:1437370582
Name:JACKSON, AMANDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27081 185TH AVE SE
Mailing Address - Street 2:STE B105
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-8448
Mailing Address - Country:US
Mailing Address - Phone:253-981-4950
Mailing Address - Fax:253-981-4952
Practice Address - Street 1:27081 185TH AVE SE
Practice Address - Street 2:STE B105
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-8448
Practice Address - Country:US
Practice Address - Phone:253-981-4950
Practice Address - Fax:253-981-4952
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54679122300000X
WADE 604473131223G0001X
KY88461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist