Healthcare Provider Details

I. General information

NPI: 1427961796
Provider Name (Legal Business Name): MARY G JACSKON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ROWE

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 CAROLINA ST
LONGVIEW WA
98632-1767
US

IV. Provider business mailing address

232 CAROLINA ST
LONGVIEW WA
98632-1767
US

V. Phone/Fax

Practice location:
  • Phone: 360-644-9734
  • Fax:
Mailing address:
  • Phone: 360-644-9734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.RN.70145517.MSL
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: