Provider Demographics
NPI:1861485773
Name:JACKSON, J KELSEY (PA -C)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:KELSEY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA -C
Other - Prefix:
Other - First Name:J
Other - Middle Name:KELSEY
Other - Last Name:LAWELLIN-JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:520 N 4TH AVE
Mailing Address - Street 2:PULMONARY SVCS
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5257
Mailing Address - Country:US
Mailing Address - Phone:509-544-6140
Mailing Address - Fax:509-544-6163
Practice Address - Street 1:520 N 4TH AVE
Practice Address - Street 2:PULMONARY SVCS
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5257
Practice Address - Country:US
Practice Address - Phone:509-544-6140
Practice Address - Fax:509-544-6163
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003084363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8900888Medicaid
WAP67183Medicare UPIN
WA8900888Medicaid