Provider Demographics
NPI:1255592754
Name:JACKSON, NICOLE DANIELLE (MS, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 SW SISKIN CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-6200
Mailing Address - Country:US
Mailing Address - Phone:360-438-4536
Mailing Address - Fax:360-438-4568
Practice Address - Street 1:5300 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-7500
Practice Address - Country:US
Practice Address - Phone:360-438-4536
Practice Address - Fax:360-438-4568
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer