Provider Demographics
NPI:1720199839
Name:JACKSON, MICHAEL BEN
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 NE LARSON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528-9404
Mailing Address - Country:US
Mailing Address - Phone:360-782-0129
Mailing Address - Fax:360-377-8029
Practice Address - Street 1:925 ADELE AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-3521
Practice Address - Country:US
Practice Address - Phone:360-782-0129
Practice Address - Fax:360-377-8029
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003880363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health