Healthcare Provider Details

I. General information

NPI: 1639299290
Provider Name (Legal Business Name): LISA A JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 MINOR AVE
SEATTLE WA
98101-1498
US

IV. Provider business mailing address

PO BOX 34584
SEATTLE WA
98124-1584
US

V. Phone/Fax

Practice location:
  • Phone: 206-442-5216
  • Fax:
Mailing address:
  • Phone: 509-241-7349
  • Fax: 509-241-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberMD00027646
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: