Provider Demographics
NPI:1215272000
Name:JACKSON, DEBORAH OLIVIA
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:OLIVIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 S HOSMER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3151
Mailing Address - Country:US
Mailing Address - Phone:253-222-6971
Mailing Address - Fax:
Practice Address - Street 1:601 S 8TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4614
Practice Address - Country:US
Practice Address - Phone:253-571-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC00000143224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant