Provider Demographics
NPI:1164121869
Name:JACKSON, MICHELLE E
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
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 1:2259 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-4664
Mailing Address - Country:US
Mailing Address - Phone:904-437-2044
Mailing Address - Fax:
Practice Address - Street 1:12297 HIDDEN HILLS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-1651
Practice Address - Country:US
Practice Address - Phone:904-699-6890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
FLMA53624225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty