Provider Demographics
NPI:1457770638
Name:JACKSON, NICOLE R (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:325 9TH AVE # 359792
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2499
Mailing Address - Country:US
Mailing Address - Phone:206-731-3505
Mailing Address - Fax:206-731-8555
Practice Address - Street 1:908 JEFFERSON ST BLDG 2ND
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2433
Practice Address - Country:US
Practice Address - Phone:206-731-3505
Practice Address - Fax:206-731-8555
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2019-0291207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology