Provider Information for 1598021081
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JERROLD JACKSON
Sex: Male
NPI: 1598021081
Last Updated: 2024-09-30
Certification Date: 2024-09-30
Certification Date: 2024-09-30
Details
| Name | Value | ||||||||||||
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| NPI | 1598021081 | ||||||||||||
| Enumeration Date | 2012-04-09 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | NO | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 10216 BEACON AVE S TUKWILA, WA 98178-2039 United States Phone: | Fax: | ||||||||||||
| Primary Practice Address | 10216 BEACON AVE S TUKWILA, WA 98178-2039 United States Phone: 425-761-9469 | Fax: | ||||||||||||
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