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NPI Code Detail

MEDICARE: GRANT W JACKSON MD PS

MEDICARE: GRANT W JACKSON MD PS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianMD60002207WA

General Provider Information

NPI Number : 1023274370
Entity Type Code : Organization
Provider Name (Legal Business Name) : GRANT W JACKSON MD PS
Provider Business Mailing Address
First Line : 319 E PIONEER AVE
Second Line :
City : MONTESANO
State : WA
Zip : 98563-4601
Country : US
Telephone Number : 360-249-1980
Fax Number :
Provider Business Practice Location Address
First Line : 319 E PIONEER AVE
Second Line :
City : MONTESANO
State : WA
Zip : 98563-4601
Country : US
Telephone Number : 360-249-1980
Fax Number :
Authorized Official
Title or Position : DIRECTOR
Name : GRANT JACKSON
Credential : MD
Telephone Number : 360-249-1980
Provider Enumeration Date : 08/05/2008
Last Update Date : 08/05/2008

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