Provider Demographics
NPI:1164952644
Name:BACKUS JACKSON, BRANDON SCOTT
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:SCOTT
Last Name:BACKUS 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 1:515 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2304
Mailing Address - Country:US
Mailing Address - Phone:206-464-1570
Mailing Address - Fax:
Practice Address - Street 1:515 3RD AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2304
Practice Address - Country:US
Practice Address - Phone:206-464-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61445547101Y00000X
WA175T00000X
101Y00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician