Provider Demographics
NPI:1376871103
Name:JACKSON, TONI M (NCTMB)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 STATE ST
Mailing Address - Street 2:HOME OFFICE
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-1355
Mailing Address - Country:US
Mailing Address - Phone:618-271-6247
Mailing Address - Fax:
Practice Address - Street 1:4806 STATE ST
Practice Address - Street 2:HOME OFFICE
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-1355
Practice Address - Country:US
Practice Address - Phone:618-225-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 225400000X, 226000000X, 226300000X
MO2005015267225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171000000XOther Service ProvidersMilitary Health Care Provider
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No226000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreational Therapist Assistant
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist