Provider Demographics
NPI:1144248014
Name:FREDRIC N. JACKSON MD INC PS
Entity type:Organization
Organization Name:FREDRIC N. JACKSON MD INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:N
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-241-1818
Mailing Address - Street 1:16259 SYLVESTER RD SW STE 404
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3059
Mailing Address - Country:US
Mailing Address - Phone:206-241-1818
Mailing Address - Fax:
Practice Address - Street 1:16259 SYLVESTER RD SW
Practice Address - Street 2:SUITE 404
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3049
Practice Address - Country:US
Practice Address - Phone:206-241-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110046684OtherRR MEDICARE
WA7144389Medicaid
WA000102480Medicare PIN