1770359879 NPI number — SONDRA ANNE JACKSON NC60519844

Table of content: SONDRA ANNE JACKSON NC60519844 (NPI 1770359879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770359879 NPI number — SONDRA ANNE JACKSON NC60519844

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SONDRA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NC60519844
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILKISON
Provider Other First Name:
SONDRA
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NC60519844
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770359879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 47877
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98504-7877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-236-4700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3835 S 312TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98001-2637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-779-7134
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2023

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: 376K00000X , 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)





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