Provider Demographics
NPI:1487005054
Name:JACKSON, EHREN (LMP)
Entity Type:Individual
Prefix:MS
First Name:EHREN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:EHREN
Other - Middle Name:
Other - Last Name:MARTORELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4214 84TH ST NE APT 5
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3457
Mailing Address - Country:US
Mailing Address - Phone:206-880-3177
Mailing Address - Fax:
Practice Address - Street 1:25 95TH DR NE STE 105
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-7976
Practice Address - Country:US
Practice Address - Phone:425-334-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2019-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60371251225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist