Provider Demographics
NPI:1194367243
Name:JACKSON, MONTRELL NIGEL (LMT,MTI,CPE)
Entity Type:Individual
Prefix:
First Name:MONTRELL
Middle Name:NIGEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMT,MTI,CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 FM 1960 RD W APT 1136
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-4122
Mailing Address - Country:US
Mailing Address - Phone:713-876-9034
Mailing Address - Fax:
Practice Address - Street 1:5959 FM 1960 RD W APT 1136
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069-4122
Practice Address - Country:US
Practice Address - Phone:713-876-9034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT119368225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist