Provider Demographics
NPI:1578760476
Name:JACKSON, SUZANNE E (AUD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4426
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:550 17TH AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5788
Practice Address - Country:US
Practice Address - Phone:206-386-3880
Practice Address - Fax:206-386-3882
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00003628231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0218398OtherSTATE L&I PROVIDER ACCT #
OR500664133Medicaid
WA1092181Medicaid
WAG8899996Medicare PIN
WA0218398OtherSTATE L&I PROVIDER ACCT #
WAG8899995Medicare PIN