Provider Demographics
NPI:1366734758
Name:JACKSON, NATHANAEL ROSS (LMP)
Entity type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:ROSS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 329
Mailing Address - Street 2:
Mailing Address - City:NAPAVINE
Mailing Address - State:WA
Mailing Address - Zip Code:98565
Mailing Address - Country:US
Mailing Address - Phone:360-266-8800
Mailing Address - Fax:360-266-8700
Practice Address - Street 1:355 LINHART AVE NE
Practice Address - Street 2:
Practice Address - City:NAPAVINE
Practice Address - State:WA
Practice Address - Zip Code:98565
Practice Address - Country:US
Practice Address - Phone:360-266-8800
Practice Address - Fax:360-266-8700
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60208070225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist