Provider Demographics
NPI:1609049451
Name:SUTHERLAND, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:SUTHERLAND
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 1:10407 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-3540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10407 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3540
Practice Address - Country:US
Practice Address - Phone:425-737-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC60013943172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker