Provider Demographics
NPI:1942753652
Name:JACKSON, ASHLEY (LMP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 TACOMA AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2264
Mailing Address - Country:US
Mailing Address - Phone:509-839-5656
Mailing Address - Fax:509-839-5682
Practice Address - Street 1:1101 TACOMA AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2264
Practice Address - Country:US
Practice Address - Phone:509-839-5656
Practice Address - Fax:509-839-5682
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60677931225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist