Provider Demographics
NPI:1184022659
Name:JACKSON, IDA OLIVIA (LAC, LMT)
Entity Type:Individual
Prefix:MISS
First Name:IDA OLIVIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N TAYLOR AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4360
Mailing Address - Country:US
Mailing Address - Phone:314-623-2302
Mailing Address - Fax:
Practice Address - Street 1:103 N TAYLOR AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4360
Practice Address - Country:US
Practice Address - Phone:314-623-2302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013032932171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist