Provider Demographics
NPI:1558923052
Name:JACKSON, AMBER HAUOLI (LMT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:HAUOLI
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 1:5820 W LOCKSLEY LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-0874
Mailing Address - Country:US
Mailing Address - Phone:907-631-2846
Mailing Address - Fax:
Practice Address - Street 1:5820 W LOCKSLEY LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-0874
Practice Address - Country:US
Practice Address - Phone:907-631-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist