Healthcare Provider Details

I. General information

NPI: 1083521314
Provider Name (Legal Business Name): JACKSON LANE ADULT FAMILY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5308 JACKSON LN
PASCO WA
99301-9756
US

IV. Provider business mailing address

5308 JACKSON LN
PASCO WA
99301-9756
US

V. Phone/Fax

Practice location:
  • Phone: 206-402-8182
  • Fax: 509-207-7943
Mailing address:
  • Phone: 206-402-8182
  • Fax: 509-207-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MARTIN NJERI
Title or Position: PROVIDER
Credential:
Phone: 206-402-8182