Provider Demographics
NPI:1679872014
Name:JACKSON, BELLE
Entity Type:Individual
Prefix:
First Name:BELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BELLE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NCTM
Mailing Address - Street 1:8390 TIPSICO TRL
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-8108
Mailing Address - Country:US
Mailing Address - Phone:810-629-4575
Mailing Address - Fax:
Practice Address - Street 1:2815 W SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2655
Practice Address - Country:US
Practice Address - Phone:810-629-4575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist