Basic Information
| Provider Information | |||||||||
| NPI: | 1013034255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DANETTE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | AU.D., CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7525 CUSTER ROAD W. | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534767327 | ||||||||
| FaxNumber: | 2534760585 | ||||||||
| Practice Location | |||||||||
| Address1: | 7525 CUSTER ROAD W. | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534767327 | ||||||||
| FaxNumber: | 2534760585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | LD00001210 | WA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 7127665 | 05 | WA | MEDICAID | 0196115 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 9058553 | 05 | WA | MEDICAID |