Provider Demographics
NPI:1437286705
Name:JACKSON, CHRISTINA R (LMT)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:R
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 1:929 N SPRING GARDEN AVE
Mailing Address - Street 2:ST. 100
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0900
Mailing Address - Country:US
Mailing Address - Phone:386-734-2592
Mailing Address - Fax:386-734-1773
Practice Address - Street 1:929 N SPRING GARDEN AVE
Practice Address - Street 2:ST. 100
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0900
Practice Address - Country:US
Practice Address - Phone:386-734-2592
Practice Address - Fax:386-734-1773
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA36547225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2264OtherBCBS OF FLORIDA