Individual
LACEY JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMP
Contact information
Practice address
712 TROSPER RD SW, TUMWATER, WA 98512-6934
(360) 570-2273
Mailing address
PO BOX 14654, TUMWATER, WA 98511-4654
(360) 570-2273
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MA00013081
WA
Other
Enumeration date
02/06/2007
Last updated
07/08/2007
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