Provider Demographics
NPI:1356464309
Name:JACKSON, PAMELA SUE (MT-BC, NMT)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:MOVED
Other - Middle Name:BY
Other - Last Name:MUSIC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2480 BIRD POINT DR
Mailing Address - Street 2:
Mailing Address - City:COTOPAXI
Mailing Address - State:CO
Mailing Address - Zip Code:81223-9302
Mailing Address - Country:US
Mailing Address - Phone:719-942-4543
Mailing Address - Fax:
Practice Address - Street 1:1540 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4511
Practice Address - Country:US
Practice Address - Phone:719-431-3549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist