Provider Demographics
NPI:1558877548
Name:JACKSON, TAYLOR MAE (CDPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 LAKEWAY DR
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5233
Mailing Address - Country:US
Mailing Address - Phone:360-676-2187
Mailing Address - Fax:
Practice Address - Street 1:515 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5233
Practice Address - Country:US
Practice Address - Phone:360-676-2187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60811500101YA0400X
WACO60811500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)