Provider Demographics
NPI:1780661694
Name:JACKSON, KATHRYN (ARNP CNM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP CNM
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP CNM
Mailing Address - Street 1:6002 WESTGATE BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2570
Mailing Address - Country:US
Mailing Address - Phone:253-509-2960
Mailing Address - Fax:253-292-1045
Practice Address - Street 1:6002 WESTGATE BLVD STE 274
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2571
Practice Address - Country:US
Practice Address - Phone:253-509-2960
Practice Address - Fax:306-400-2735
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025801 RN00121312163W00000X
WAAP30003731363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8895828OtherMEDICARE
WA9620246Medicaid
WAJA7565OtherREGENCE
WA0270551OtherL&I