Provider Demographics
NPI:1235916503
Name:JACKSON, KOURTNEY ALMEITHA
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:ALMEITHA
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 1:7437 PATRICIAN RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-4323
Mailing Address - Country:US
Mailing Address - Phone:757-809-6386
Mailing Address - Fax:
Practice Address - Street 1:7437 PATRICIAN RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-4323
Practice Address - Country:US
Practice Address - Phone:757-809-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019019400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist