MEDICARE: JACKSON WILLIAM PECKENPAUGH PT, DPT

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	225100000X	Physical Therapist	PT.PT.70132648	WA

General Provider Information

NPI Number	:	1932034683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON WILLIAM PECKENPAUGH PT, DPT

Provider Business Mailing Address
First Line	:	8209 144TH DR SE
Second Line	:
City	:	SNOHOMISH
State	:	WA
Zip	:	98290-9079
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	161 LINCOLN AVE STE 120
Second Line	:
City	:	SNOHOMISH
State	:	WA
Zip	:	98290-3053
Country	:	US
Telephone Number	:	360-822-9068
Fax Number	:

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

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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