Provider Demographics
NPI:1851305866
Name:JACKSON, CHARLES G (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98071-0632
Mailing Address - Country:US
Mailing Address - Phone:425-454-2191
Mailing Address - Fax:425-453-1270
Practice Address - Street 1:1200 112TH AVE NE
Practice Address - Street 2:SUITE C-210
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3732
Practice Address - Country:US
Practice Address - Phone:425-454-2191
Practice Address - Fax:425-453-1270
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014267207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1039247Medicaid
WAG217000382Medicare PIN
AKK0000BLBDQMedicare PIN
WA1039247Medicaid