Provider Demographics
NPI:1861109001
Name:JACKSON, MADISON (BA & BS)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BA & BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 MITCHELL RD SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4413
Mailing Address - Country:US
Mailing Address - Phone:360-865-2022
Mailing Address - Fax:
Practice Address - Street 1:3100 NW BUCKLIN HILL RD
Practice Address - Street 2:#215
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8363
Practice Address - Country:US
Practice Address - Phone:360-337-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst