Provider Demographics
NPI:1891436416
Name:JACKSON, DIANNA E (LMT)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4656 SAINT FRANCIS AVE APT 411
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-1898
Mailing Address - Country:US
Mailing Address - Phone:214-515-2585
Mailing Address - Fax:
Practice Address - Street 1:4656 SAINT FRANCIS AVE APT 411
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-1898
Practice Address - Country:US
Practice Address - Phone:214-515-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134447225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist