1699036756 NPI number — IVETTE SYRA JACKSON APRN-NP

Table of content: IVETTE SYRA JACKSON APRN-NP (NPI 1699036756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699036756 NPI number — IVETTE SYRA JACKSON APRN-NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
IVETTE
Provider Middle Name:
SYRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YAMAMOTO
Provider Other First Name:
IVETTE
Provider Other Middle Name:
SYRA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699036756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24312 E MAIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAMMAMISH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98074-3460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-449-0452
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 MARTIN LUTHER KING JR WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-403-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LN0005X , with the licence number:  95007329 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0005X , with the licence number: 111345 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0005X , with the licence number: ARNP 9350748 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0005X , with the licence number: AP61619732 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)