Provider Demographics
NPI:1639535719
Name:JACKSON, KIMBERLY RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
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 1:9175 CYPRESS WATERS BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-5068
Mailing Address - Country:US
Mailing Address - Phone:404-427-8793
Mailing Address - Fax:
Practice Address - Street 1:9175 CYPRESS WATERS BLVD APT 102
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5068
Practice Address - Country:US
Practice Address - Phone:404-427-8793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010418225700000X
TXMT126228225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist