Basic Information
Provider Information | |||||||||
NPI: | 1811282247 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | ALLEN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S.W. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5209 POINT FOSDICK DR NW STE 205 | ||||||||
Address2: |   | ||||||||
City: | GIG HARBOR | ||||||||
State: | WA | ||||||||
PostalCode: | 983351728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534959311 | ||||||||
FaxNumber: | 2536973730 | ||||||||
Practice Location | |||||||||
Address1: | 5209 POINT FOSDICK DR NW STE 205 | ||||||||
Address2: |   | ||||||||
City: | GIG HARBOR | ||||||||
State: | WA | ||||||||
PostalCode: | 98335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534959311 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2011 | ||||||||
LastUpdateDate: | 05/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | LW00004709 | WA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | LW00004709 | 01 | WA | WA STATE DEPARTMENT OF HEALTH | OTHER |