Healthcare Provider Details

I. General information

NPI: 1578756540
Provider Name (Legal Business Name): SUSAN VARNER JACKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 1ST AVE S SUITE C
SEATTLE WA
98134-1850
US

IV. Provider business mailing address

18323 BOTHELL EVERETT HWY SUITE 220
BOTHELL WA
98012-5246
US

V. Phone/Fax

Practice location:
  • Phone: 206-624-3651
  • Fax: 206-624-2391
Mailing address:
  • Phone: 425-806-5700
  • Fax: 425-806-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004092
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: