Provider Demographics
NPI:1417131269
Name:JACKSON, CRISTINA ANN (LMT)
Entity Type:Individual
Prefix:MISS
First Name:CRISTINA
Middle Name:ANN
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 1:112 PINEWOOD TER
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-6328
Mailing Address - Country:US
Mailing Address - Phone:850-496-7602
Mailing Address - Fax:
Practice Address - Street 1:112 PINEWOOD TER
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-6328
Practice Address - Country:US
Practice Address - Phone:850-496-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2008-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA49020225700000X
LALA2767225700000X
334604-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist