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General NPI Number Information
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NPI Number | 1366701849
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Entity Type | Organization
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Legal Business Name | MICHAEL R. JACKSON, M.D. P.S.
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Dates
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Enumeration Date | 05/03/2012
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Last Update Date | 05/03/2012
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Provider Practice Location Address
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Address Line | 5350 ORCHARD ST W SUITE 202
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City | UNIVERSITY PLACE
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State | WA
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Zip | 98467-4817
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Country | US
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Telephone | 253-472-4444
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Fax |
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Provider Business Mailing Address
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Address Line | 5350 ORCHARD ST W SUITE 202
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City | UNIVERSITY PLACE
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State | WA
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Zip | 98467-4817
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Country | US
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Telephone | 253-472-4444
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL R JACKSON
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Credential | M.D.
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Telephone | 253-472-4444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0019523
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License Number State | WA
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