Healthcare Provider Details

I. General information

NPI: 1902616881
Provider Name (Legal Business Name): ALAN STANLEY JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10811 W 6TH AVE
AIRWAY HEIGHTS WA
99001-5345
US

IV. Provider business mailing address

1015 S PEPPER TREE LN
SPOKANE WA
99224-2063
US

V. Phone/Fax

Practice location:
  • Phone: 509-481-4990
  • Fax:
Mailing address:
  • Phone: 808-333-0245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN00124636
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: