Provider Demographics
NPI:1881289338
Name:JACKSON, KEITH ELLIS (LMFT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ELLIS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 NE 13TH PL
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-9534
Mailing Address - Country:US
Mailing Address - Phone:360-852-8139
Mailing Address - Fax:360-852-8139
Practice Address - Street 1:7600 NE 41ST ST STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6772
Practice Address - Country:US
Practice Address - Phone:360-852-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61192417106H00000X
CA48284106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist