Provider Demographics
NPI:1851075477
Name:LIKENS, JACKSON GREY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:GREY
Last Name:LIKENS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18012 68TH AVE S STE 101
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-1022
Mailing Address - Country:US
Mailing Address - Phone:425-291-3300
Mailing Address - Fax:
Practice Address - Street 1:3651 ASHWORTH AVE N UNIT B
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8116
Practice Address - Country:US
Practice Address - Phone:407-927-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9116959363A00000X
WAPA61450103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant