Basic Information
| Provider Information | |||||||||
| NPI: | 1275068892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ELISHIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LAT, ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDRADA | ||||||||
| OtherFirstName: | ELISHIA | ||||||||
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| OtherCredential: | LAT, ATC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 417 W YELM AVE | ||||||||
| Address2: | |||||||||
| City: | YELM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604582444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 417 W. YELM AVE. | ||||||||
| Address2: | |||||||||
| City: | YELM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604582444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2017 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | A160668335 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.