Provider Demographics
NPI:1659897593
Name:JACKSON, LAMECIA LASHAY (LMT, CA)
Entity Type:Individual
Prefix:
First Name:LAMECIA
Middle Name:LASHAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT, CA
Other - Prefix:
Other - First Name:LAMECIA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT, CA
Mailing Address - Street 1:5830 W THUNDERBIRD RD # B8216
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4654
Mailing Address - Country:US
Mailing Address - Phone:623-203-8864
Mailing Address - Fax:
Practice Address - Street 1:530 N ESTRELLA PKWY
Practice Address - Street 2:#0-1
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338
Practice Address - Country:US
Practice Address - Phone:623-932-9211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-07028225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty