Provider Demographics
NPI:1699036756
Name:JACKSON, IVETTE SYRA (APRN-NP)
Entity type:Individual
Prefix:
First Name:IVETTE
Middle Name:SYRA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN-NP
Other - Prefix:
Other - First Name:IVETTE
Other - Middle Name:SYRA
Other - Last Name:YAMAMOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24312 E MAIN DR
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-3460
Mailing Address - Country:US
Mailing Address - Phone:323-449-0452
Mailing Address - Fax:
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4291
Practice Address - Country:US
Practice Address - Phone:253-403-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007329363LN0005X
NE111345363LN0005X
FLARNP 9350748363LN0005X
WAAP61619732363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care