Provider Demographics
NPI:1609942531
Name:JACKSON, MATTHEW BRYAN (LMP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BRYAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SW BARTON STREET
Mailing Address - Street 2:SUITE A24
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126
Mailing Address - Country:US
Mailing Address - Phone:206-453-5397
Mailing Address - Fax:206-453-5630
Practice Address - Street 1:2600 SW BARTON STREET
Practice Address - Street 2:SUITE A24
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126
Practice Address - Country:US
Practice Address - Phone:206-453-5397
Practice Address - Fax:206-453-5630
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10723225700000X
WAMA60423885225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist