Healthcare Provider Details

I. General information

NPI: 1376163774
Provider Name (Legal Business Name): RENEE JACKSON RT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2020
Last Update Date: 04/26/2020
Certification Date: 04/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE
SEATTLE WA
98104-2499
US

IV. Provider business mailing address

12528 22ND STREET CT E
EDGEWOOD WA
98372-1698
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-0133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: