MEDICARE: ANDREW JACKSON

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
1	175F00000X	Naturopath	NT60704271	WA

General Provider Information

NPI Number	:	1285177253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW JACKSON

Provider Business Mailing Address
First Line	:	12025 LAKE CITY WAY NE STE B
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-5331
Country	:	US
Telephone Number	:	860-916-4708
Fax Number	:

Provider Business Practice Location Address
First Line	:	12025 LAKE CITY WAY NE STE B
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-5331
Country	:	US
Telephone Number	:	860-916-4708
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2016
Last Update Date	:	03/17/2018

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