Provider Demographics
NPI:1881407443
Name:JACKMAN, LORRAINE MARIE
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:MARIE
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10049 KITSAP MALL BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8903
Mailing Address - Country:US
Mailing Address - Phone:360-373-6966
Mailing Address - Fax:360-373-6965
Practice Address - Street 1:8627 TRACYTON BLVD NW
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-9068
Practice Address - Country:US
Practice Address - Phone:360-373-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00058516164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse