Provider Demographics
NPI:1679720619
Name:JACKSON, DANYIELLE (LMT-NCTM)
Entity Type:Individual
Prefix:
First Name:DANYIELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT-NCTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 SPRING CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1688
Mailing Address - Country:US
Mailing Address - Phone:256-759-8352
Mailing Address - Fax:
Practice Address - Street 1:323 SPRING CREEK WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1688
Practice Address - Country:US
Practice Address - Phone:256-759-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005209225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist