Active NPI
Robert Tyrone Jackson
- Peer Specialist
- Yakima, WA
National Provider Identifier
1043181613
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Peer Specialist
- License
- CG-70001630
- Practice address
- 120 S 3Rd St
Yakima, WA 98901-2875 - Phone
- (509) 571-1537
- NPI assigned
- Sep 16, 2025
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Peer Specialist | 175T00000X | CG-70001630 | WA | Primary |
Addresses
Primary practice location
120 S 3Rd St
Yakima, WA 98901-2875
Mailing address
120 S 3Rd St
Yakima, WA 98901-2875
Phone (509) 571-1537
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 91-0755984 | Medicaid | WA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| CG-70001630 | WA | MD | Peer Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1757980800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1757980800000",
"number": "1043181613",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "120 S 3RD ST",
"city": "YAKIMA",
"state": "WA",
"postal_code": "989012875",
"telephone_number": "509-571-1537"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "120 S 3RD ST",
"city": "YAKIMA",
"state": "WA",
"postal_code": "989012875",
"telephone_number": "509-571-1537"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "ROBERT",
"middle_name": "TYRONE",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2025-09-16",
"last_updated": "2025-09-16",
"certification_date": "2025-09-16",
"status": "A"
},
"taxonomies": [
{
"code": "175T00000X",
"taxonomy_group": "",
"desc": "Peer Specialist",
"state": "WA",
"license": "CG-70001630",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "91-0755984",
"state": "WA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Yakima, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 16, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.