Provider Demographics
NPI:1457502346
Name:JACKSON, ROBERTA ANN (LMT)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
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 1:294 BAY ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-1834
Mailing Address - Country:US
Mailing Address - Phone:508-880-3324
Mailing Address - Fax:
Practice Address - Street 1:294 BAY ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-1834
Practice Address - Country:US
Practice Address - Phone:508-880-3324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2951225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist