Provider Demographics
NPI:1770655979
Name:JACKSON, BRIAN JAMES (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 MARTIN WAY E
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5220
Mailing Address - Country:US
Mailing Address - Phone:360-456-8610
Mailing Address - Fax:360-493-8179
Practice Address - Street 1:3924 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5220
Practice Address - Country:US
Practice Address - Phone:360-456-8610
Practice Address - Fax:360-493-8179
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61281223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5030374Medicaid
WAG8867313Medicare PIN