Individual
TOMMY LAMAR JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1802 YAKIMA AVE STE 204, TACOMA, WA 98405-5304
(253) 382-8540
Mailing address
1802 YAKIMA AVE STE 204, TACOMA, WA 98405-5304
(253) 382-8540
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA60988499
WA
363AS0400X
Surgical Physician Assistant
004173
GA
363AS0400X
Surgical Physician Assistant
PA60988499
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2150243
—
WA
Enumeration date
08/13/2006
Last updated
12/04/2020
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