Healthcare Provider Details

I. General information

NPI: 1427128867
Provider Name (Legal Business Name): ERIK R JACKSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 12TH AVE
SEATTLE WA
98122-4410
US

IV. Provider business mailing address

1421 15TH AVE APT 204
SEATTLE WA
98122-4169
US

V. Phone/Fax

Practice location:
  • Phone: 206-329-5255
  • Fax: 206-726-1878
Mailing address:
  • Phone: 206-329-5255
  • Fax: 206-726-1878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00003518
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: