Provider Demographics
NPI:1629449095
Name:JACKSON, ZANETA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:ZANETA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 MANSELL RD
Mailing Address - Street 2:SUITE #234
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-4850
Mailing Address - Country:US
Mailing Address - Phone:678-414-2714
Mailing Address - Fax:
Practice Address - Street 1:1655 MANSELL RD
Practice Address - Street 2:SUITE #234
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-4850
Practice Address - Country:US
Practice Address - Phone:678-414-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000331225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist