Provider Demographics
NPI:1356628325
Name:WILSON, JACKIE (LMT)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 N RANGE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-2407
Mailing Address - Country:US
Mailing Address - Phone:225-791-8154
Mailing Address - Fax:225-791-8152
Practice Address - Street 1:1019 N RANGE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-2407
Practice Address - Country:US
Practice Address - Phone:225-791-8154
Practice Address - Fax:225-791-8152
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1169173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist