Provider Demographics
NPI:1093280422
Name:JACKSON, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10820 S SHORE DR APT 13
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-4970
Mailing Address - Country:US
Mailing Address - Phone:612-242-9536
Mailing Address - Fax:
Practice Address - Street 1:3647 CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-2919
Practice Address - Country:US
Practice Address - Phone:612-728-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist