Provider Demographics
NPI:1528207180
Name:JACKSON, MARY ANN (NCTMB)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 HILLER ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-2622
Mailing Address - Country:US
Mailing Address - Phone:586-206-0348
Mailing Address - Fax:
Practice Address - Street 1:28000 HILLER ST
Practice Address - Street 2:
Practice Address - City:HARRISON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48045-2622
Practice Address - Country:US
Practice Address - Phone:586-206-0348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist