Provider Demographics
NPI:1902537004
Name:JACKSON, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASIA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22327 MERIDIAN AVE S
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8311
Mailing Address - Country:US
Mailing Address - Phone:425-236-3569
Mailing Address - Fax:
Practice Address - Street 1:18422 103RD AVE NE
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3410
Practice Address - Country:US
Practice Address - Phone:425-949-0801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABAC804127106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician