Provider Demographics
NPI:1053192377
Name:JACKSON, MISHELLE (SUDPT)
Entity type:Individual
Prefix:
First Name:MISHELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:TAHOLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98587-0219
Mailing Address - Country:US
Mailing Address - Phone:360-276-8215
Mailing Address - Fax:
Practice Address - Street 1:1505 KLA-OOK-WA DR
Practice Address - Street 2:
Practice Address - City:TAHOLAH
Practice Address - State:WA
Practice Address - Zip Code:98587
Practice Address - Country:US
Practice Address - Phone:360-276-8215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO-61267571101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)