Provider Demographics
NPI:1326570383
Name:JACKSON, AMI (DO)
Entity type:Individual
Prefix:DR
First Name:AMI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7921
Mailing Address - Country:US
Mailing Address - Phone:537-986-4942
Mailing Address - Fax:
Practice Address - Street 1:3619 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7921
Practice Address - Country:US
Practice Address - Phone:253-798-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP61585845207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program