Provider Demographics
NPI:1598819567
Name:JACKSON, BRUCE E (MA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 WAGNER WAY STE 320
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-8392
Mailing Address - Country:US
Mailing Address - Phone:253-858-7056
Mailing Address - Fax:253-858-8028
Practice Address - Street 1:6625 WAGNER WAY STE 320
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8392
Practice Address - Country:US
Practice Address - Phone:253-858-7056
Practice Address - Fax:253-858-8028
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011181101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health