Provider Demographics
NPI:1659973220
Name:JACKSON, EMILY (LMT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
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 1:740 E WARM SPRINGS RD APT 214
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-6341
Mailing Address - Country:US
Mailing Address - Phone:619-729-1460
Mailing Address - Fax:
Practice Address - Street 1:740 E WARM SPRINGS RD APT 214
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-6341
Practice Address - Country:US
Practice Address - Phone:619-729-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9924225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist