Provider Demographics
NPI:1467670067
Name:JACKSON, MARY KATHERINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 WHISPERING PINE LN
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-7827
Mailing Address - Country:US
Mailing Address - Phone:360-240-0770
Mailing Address - Fax:
Practice Address - Street 1:343 WHISPERING PINE LN
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-7827
Practice Address - Country:US
Practice Address - Phone:360-240-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00140746163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse