Provider Demographics
NPI:1306901475
Name:JACKSON, GRANT WELLS (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:WELLS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:319 E PIONEER AVE
Mailing Address - Street 2:GRANT W JACKSON MD PS
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-4601
Mailing Address - Country:US
Mailing Address - Phone:360-249-1980
Mailing Address - Fax:360-249-1993
Practice Address - Street 1:319 E PIONEER AVE
Practice Address - Street 2:GRANT W JACKSON MD PS
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4601
Practice Address - Country:US
Practice Address - Phone:360-249-1980
Practice Address - Fax:360-249-1993
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAML002797207P00000X, 207Q00000X
WAMD60002207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine