Provider Demographics
NPI:1356955751
Name:JACKSON, MACKENZIE NICOLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11212 SUNRISE BLVD E STE 202
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8847
Mailing Address - Country:US
Mailing Address - Phone:253-435-0360
Mailing Address - Fax:253-435-0325
Practice Address - Street 1:11212 SUNRISE BLVD E STE 202
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8847
Practice Address - Country:US
Practice Address - Phone:253-435-0360
Practice Address - Fax:253-435-0325
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019681225100000X
WAPT61528942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist