Provider Demographics
NPI:1679341762
Name:JACKSON ROYAL, KIMMISHA
Entity Type:Individual
Prefix:
First Name:KIMMISHA
Middle Name:
Last Name:JACKSON ROYAL
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 1:9712 18TH AVENUE CT S APT R14
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-6638
Mailing Address - Country:US
Mailing Address - Phone:253-355-7097
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DR SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-6638
Practice Address - Country:US
Practice Address - Phone:253-582-8440
Practice Address - Fax:253-589-4143
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61492022164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse