Provider Demographics
NPI:1942734884
Name:JACKSON, ADAM (CDPT)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21324 SISTER SKY LN NE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:WA
Mailing Address - Zip Code:98342-9706
Mailing Address - Country:US
Mailing Address - Phone:360-535-4535
Mailing Address - Fax:
Practice Address - Street 1:31912 LITTLE BOSTON RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9700
Practice Address - Country:US
Practice Address - Phone:360-297-6329
Practice Address - Fax:360-297-9678
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60375850101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)