MEDICARE: GEORGE F. JACKSON III M.D.

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	2084P0800X	Psychiatry Physician	MD00039825	WA

General Provider Information

NPI Number	:	1932245032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE F. JACKSON III M.D.

Provider Business Mailing Address
First Line	:	5909 ORCHARD ST W
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98467-3824
Country	:	US
Telephone Number	:	253-475-6021
Fax Number	:	253-474-1871

Provider Business Practice Location Address
First Line	:	5909 ORCHARD ST W
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98467-3824
Country	:	US
Telephone Number	:	253-475-6021
Fax Number	:	253-474-1871

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/09/2007

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