Provider Demographics
NPI:1902616881
Name:JACKSON, ALAN STANLEY
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:STANLEY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S PEPPER TREE LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-2063
Mailing Address - Country:US
Mailing Address - Phone:808-333-0245
Mailing Address - Fax:
Practice Address - Street 1:10811 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:AIRWAY HEIGHTS
Practice Address - State:WA
Practice Address - Zip Code:99001-5345
Practice Address - Country:US
Practice Address - Phone:509-481-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00124636163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty