Provider Demographics
NPI:1417615170
Name:JACKSON, MARJORIE M (LMP)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N MISSION ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-6612
Mailing Address - Country:US
Mailing Address - Phone:509-662-4711
Mailing Address - Fax:
Practice Address - Street 1:610 N MISSION ST STE 102
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6612
Practice Address - Country:US
Practice Address - Phone:509-662-4711
Practice Address - Fax:509-662-2800
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60369689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist