Provider Demographics
NPI:1407235922
Name:JACKSON, JODY M
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:M
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 1:33 WENTWORTH AVE E
Mailing Address - Street 2:SUITE 240
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3431
Mailing Address - Country:US
Mailing Address - Phone:612-770-7565
Mailing Address - Fax:
Practice Address - Street 1:33 WENTWORTH AVE E
Practice Address - Street 2:SUITE 240
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3431
Practice Address - Country:US
Practice Address - Phone:612-770-7565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN153830-6172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist