Healthcare Provider Details

I. General information

NPI: 1982147682
Provider Name (Legal Business Name): ERIN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 NW MYHRE RD STE 102
SILVERDALE WA
98383-7672
US

IV. Provider business mailing address

19319 7TH AVE NE
POULSBO WA
98370-7442
US

V. Phone/Fax

Practice location:
  • Phone: 360-613-1834
  • Fax:
Mailing address:
  • Phone: 360-598-3764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT60136460
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: