Healthcare Provider Details

I. General information

NPI: 1245856830
Provider Name (Legal Business Name): JACKIE C TOH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13684 18TH AVE SW
BURIEN WA
98166-1047
US

IV. Provider business mailing address

13684 18TH AVE SW
BURIEN WA
98166-1047
US

V. Phone/Fax

Practice location:
  • Phone: 206-549-7269
  • Fax:
Mailing address:
  • Phone: 206-549-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00018283
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: