Provider Demographics
NPI:1437431889
Name:JACKSON, DEAN ROBERT (LMP)
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:ROBERT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:DEAN
Other - Middle Name:ROBERT
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:200 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3219
Mailing Address - Country:US
Mailing Address - Phone:360-907-1109
Mailing Address - Fax:
Practice Address - Street 1:200 E 25TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3219
Practice Address - Country:US
Practice Address - Phone:360-907-1109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00013622173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist