Provider Demographics
NPI:1487491866
Name:JACKSON, TRISA (IHP)
Entity type:Individual
Prefix:
First Name:TRISA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:IHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14005 95TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98329-7226
Mailing Address - Country:US
Mailing Address - Phone:253-255-7788
Mailing Address - Fax:
Practice Address - Street 1:11505 BURNHAM DR STE 103
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-9173
Practice Address - Country:US
Practice Address - Phone:253-255-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach