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NPI Code Detail

MEDICARE: GRANT WELLS JACKSON MD

MEDICARE: GRANT WELLS JACKSON MD
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
1207P00000XEmergency Medicine PhysicianML002797PA
2207Q00000XFamily Medicine PhysicianML002797PA
3207Q00000XFamily Medicine PhysicianMD60002207WA

General Provider Information

NPI Number : 1306901475
Entity Type Code : Individual
Provider Name (Legal Business Name) : GRANT WELLS JACKSON MD
Provider Business Mailing Address
First Line : 319 E PIONEER AVE
Second Line : GRANT W JACKSON MD PS
City : MONTESANO
State : WA
Zip : 98563-4601
Country : US
Telephone Number : 360-249-1980
Fax Number : 360-249-1993
Provider Business Practice Location Address
First Line : 319 E PIONEER AVE
Second Line : GRANT W JACKSON MD PS
City : MONTESANO
State : WA
Zip : 98563-4601
Country : US
Telephone Number : 360-249-1980
Fax Number : 360-249-1993
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/27/2006
Last Update Date : 08/04/2008

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