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NPI Code Detail

MEDICARE: KEIRA JACK

MEDICARE: KEIRA JACK
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
1363A00000XPhysician AssistantPA61041267WA
2363A00000XPhysician Assistant

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1NAOTHERN/A

General Provider Information

NPI Number : 1780170399
Entity Type Code : Individual
Provider Name (Legal Business Name) : KEIRA JACK
Provider Business Mailing Address
First Line : 1701 18TH AVE S
Second Line :
City : SEATTLE
State : WA
Zip : 98144-4317
Country : US
Telephone Number : 616-206-4359
Fax Number :
Provider Business Practice Location Address
First Line : 1701 18TH AVE S
Second Line :
City : SEATTLE
State : WA
Zip : 98144-4317
Country : US
Telephone Number : 253-833-7444
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/06/2018
Last Update Date : 04/24/2020

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Directions to “ KEIRA JACK ” Practice Location

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