Provider Demographics
NPI:1558472688
Name:JACKSON, MATTI
Entity Type:Individual
Prefix:
First Name:MATTI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MATTI
Other - Middle Name:
Other - Last Name:REEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:407 ULUNIU ST STE 301
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2544
Mailing Address - Country:US
Mailing Address - Phone:808-261-4321
Mailing Address - Fax:808-261-4320
Practice Address - Street 1:407 ULUNIU ST STE 301
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2544
Practice Address - Country:US
Practice Address - Phone:808-261-4321
Practice Address - Fax:808-261-4320
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist