Healthcare Provider Details

I. General information

NPI: 1285286534
Provider Name (Legal Business Name): TREVOR REID JACKMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 EUREKA WAY
SEQUIM WA
98382-5074
US

IV. Provider business mailing address

541 EUREKA WAY
SEQUIM WA
98382-5074
US

V. Phone/Fax

Practice location:
  • Phone: 360-582-0808
  • Fax: 360-682-2712
Mailing address:
  • Phone: 360-582-0808
  • Fax: 360-682-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61104032
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61104032
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: