Provider Demographics
NPI:1073383204
Name:JACKSON-MATU, ALEXANDER (LMT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:JACKSON-MATU
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 W BROAD ST UNIT 331
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-4945
Mailing Address - Country:US
Mailing Address - Phone:614-378-2722
Mailing Address - Fax:
Practice Address - Street 1:4906 FITZHUGH AVE STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3520
Practice Address - Country:US
Practice Address - Phone:614-378-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1261000096225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist