Provider Demographics
NPI:1679851240
Name:JACKSON, MARK (LMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12795 SAN JOSE BLVD
Mailing Address - Street 2:STE 9
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2669
Mailing Address - Country:US
Mailing Address - Phone:904-415-6744
Mailing Address - Fax:
Practice Address - Street 1:12795 SAN JOSE BLVD
Practice Address - Street 2:STE 9
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2669
Practice Address - Country:US
Practice Address - Phone:904-415-6744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL54995225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist