Provider Demographics
NPI:1558024380
Name:JACKSON-OMAN, PEGGY ANN
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:JACKSON-OMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7311 59TH ST NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-8883
Mailing Address - Country:US
Mailing Address - Phone:360-658-5315
Mailing Address - Fax:
Practice Address - Street 1:14692 179TH AVE SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1198
Practice Address - Country:US
Practice Address - Phone:360-804-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60680388235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist