Provider Demographics
NPI:1801951959
Name:JACKSON, TAMARA E (PA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 16TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-5226
Mailing Address - Country:US
Mailing Address - Phone:206-326-3000
Mailing Address - Fax:
Practice Address - Street 1:201 16TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5226
Practice Address - Country:US
Practice Address - Phone:206-326-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004632363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8392045Medicaid
WA8392045Medicaid
WAG8804159Medicare PIN
WAG8804165Medicare PIN
WAP37465Medicare UPIN
WAG8804157Medicare PIN
WAG8804163Medicare PIN
WAG8872391Medicare PIN