Provider Demographics
NPI:1811233638
Name:JACKSON, MARTINEE LASHUNN
Entity Type:Individual
Prefix:
First Name:MARTINEE
Middle Name:LASHUNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W BROADWAY
Mailing Address - Street 2:STE 5010
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4431
Mailing Address - Country:US
Mailing Address - Phone:562-304-6930
Mailing Address - Fax:
Practice Address - Street 1:100 W BROADWAY
Practice Address - Street 2:STE 5010
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4431
Practice Address - Country:US
Practice Address - Phone:562-304-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-26
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner