Provider Demographics
NPI:1982715207
Name:JACKSON, BENJAMIN K
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:K
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 1:1100 9TH AVE
Mailing Address - Street 2:MS: M4-PFS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:2671 NE 46TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5041
Practice Address - Country:US
Practice Address - Phone:206-585-8000
Practice Address - Fax:206-525-8070
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20008448208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8531386Medicaid
WAG8884104Medicare PIN