Provider Demographics
NPI:1750004560
Name:JACKSON, ASHLEY DASHAWN
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DASHAWN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3378 SHADDEN LN NW APT 101
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1315
Mailing Address - Country:US
Mailing Address - Phone:904-729-9901
Mailing Address - Fax:
Practice Address - Street 1:5050 WA-303
Practice Address - Street 2:SUITE A101
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311
Practice Address - Country:US
Practice Address - Phone:360-627-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61352085225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist