Provider Demographics
NPI:1386862605
Name:JACKSON, MARTHA SUE (LMT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:SUE
Last Name:JACKSON
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:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-0362
Mailing Address - Country:US
Mailing Address - Phone:304-548-4441
Mailing Address - Fax:
Practice Address - Street 1:888 OAKWOOD RD
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2000
Practice Address - Country:US
Practice Address - Phone:304-550-9724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2003-1320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist