Provider Demographics
NPI:1548539703
Name:JACKSON, JAMES A (LMP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2051
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-0240
Mailing Address - Country:US
Mailing Address - Phone:360-643-1169
Mailing Address - Fax:360-406-6958
Practice Address - Street 1:219 W PATISON ST
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9710
Practice Address - Country:US
Practice Address - Phone:360-643-1169
Practice Address - Fax:360-406-6958
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-17
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60262912225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist