Provider Demographics
NPI:1639294325
Name:JACKSON, DEBORAH GAIL (LMT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:GAIL
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 1:10738 PREBLE CO LINE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309
Mailing Address - Country:US
Mailing Address - Phone:937-277-7246
Mailing Address - Fax:937-277-3719
Practice Address - Street 1:2601 NEEDMORE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414
Practice Address - Country:US
Practice Address - Phone:937-277-7246
Practice Address - Fax:937-277-3719
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33012939225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist