Provider Demographics
NPI:1548412471
Name:JACKSON, MIMI C (DC)
Entity Type:Individual
Prefix:DR
First Name:MIMI
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 N 45TH ST. STE 105
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103
Mailing Address - Country:US
Mailing Address - Phone:206-259-8882
Mailing Address - Fax:
Practice Address - Street 1:2319 N 45TH ST. STE 105
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103
Practice Address - Country:US
Practice Address - Phone:206-259-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60044896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor