Provider Demographics
NPI:1538867882
Name:KINGSADA, JACKY (NP)
Entity type:Individual
Prefix:
First Name:JACKY
Middle Name:
Last Name:KINGSADA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4305
Mailing Address - Country:US
Mailing Address - Phone:253-204-9386
Mailing Address - Fax:
Practice Address - Street 1:195 NE GILMAN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2940
Practice Address - Country:US
Practice Address - Phone:253-204-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61412255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty