Provider Demographics
NPI:1831354661
Name:SULLIVAN, MARCY JACKSON (DC)
Entity type:Individual
Prefix:DR
First Name:MARCY
Middle Name:JACKSON
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 CLARK PL SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4062
Mailing Address - Country:US
Mailing Address - Phone:360-570-0332
Mailing Address - Fax:360-570-2060
Practice Address - Street 1:205 CLARK PL SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4062
Practice Address - Country:US
Practice Address - Phone:360-570-0332
Practice Address - Fax:360-570-2060
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60030710111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7486SUOtherREGENCE
WA0243388OtherLABOR AND INDUSTRIES
WA7486SUOtherREGENCE