Provider Demographics
NPI:1427128867
Name:JACKSON, ERIK R (PHD)
Entity type:Individual
Prefix:DR
First Name:ERIK
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 15TH AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4169
Mailing Address - Country:US
Mailing Address - Phone:206-329-5255
Mailing Address - Fax:206-726-1878
Practice Address - Street 1:818 12TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4410
Practice Address - Country:US
Practice Address - Phone:206-329-5255
Practice Address - Fax:206-726-1878
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003518103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical