Provider Demographics
NPI:1710562863
Name:JACKSON, KODI (LMT)
Entity Type:Individual
Prefix:
First Name:KODI
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 1:248 KIPPER AVE
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-4324
Mailing Address - Country:US
Mailing Address - Phone:210-315-7510
Mailing Address - Fax:
Practice Address - Street 1:248 KIPPER AVE
Practice Address - Street 2:
Practice Address - City:CIBOLO
Practice Address - State:TX
Practice Address - Zip Code:78108-4324
Practice Address - Country:US
Practice Address - Phone:210-315-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT127777225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist