Healthcare Provider Details

I. General information

NPI: 1053324186
Provider Name (Legal Business Name): TOMMY LAMAR JACKSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 YAKIMA AVE STE 204
TACOMA WA
98405-5304
US

IV. Provider business mailing address

1802 YAKIMA AVE STE 204
TACOMA WA
98405-5304
US

V. Phone/Fax

Practice location:
  • Phone: 253-382-8540
  • Fax:
Mailing address:
  • Phone: 253-382-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60988499
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60988499
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number004173
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: