Provider Demographics
NPI:1114206232
Name:JACKSON, ANNA ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2313
Mailing Address - Country:US
Mailing Address - Phone:503-842-6532
Mailing Address - Fax:503-842-5191
Practice Address - Street 1:309 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-2313
Practice Address - Country:US
Practice Address - Phone:503-842-6532
Practice Address - Fax:503-842-5191
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18284225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist