Provider Demographics
NPI:1619289212
Name:JACKSON, TIFFANY C (LMT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:C
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 1:904 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3560
Mailing Address - Country:US
Mailing Address - Phone:801-687-3957
Mailing Address - Fax:
Practice Address - Street 1:140 S MAIN ST #3
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3560
Practice Address - Country:US
Practice Address - Phone:801-899-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6077621-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist