Healthcare Provider Details

I. General information

NPI: 1992780159
Provider Name (Legal Business Name): DAVID B JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E MANITOBA AVE STE 101
ELLENSBURG WA
98926-3885
US

IV. Provider business mailing address

700 E MANITOBA AVE STE 101
ELLENSBURG WA
98926-3885
US

V. Phone/Fax

Practice location:
  • Phone: 509-925-6100
  • Fax: 509-925-7604
Mailing address:
  • Phone: 509-925-6100
  • Fax: 509-925-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00025572
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: