Provider Demographics
NPI:1891861860
Name:JACKSON-SMITH, GINA T (LMT)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:T
Last Name:JACKSON-SMITH
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 1:208 N. ST. MARY
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633
Mailing Address - Country:US
Mailing Address - Phone:903-694-2202
Mailing Address - Fax:903-694-2202
Practice Address - Street 1:208 N SAINT MARY ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-1806
Practice Address - Country:US
Practice Address - Phone:903-694-2202
Practice Address - Fax:903-694-2202
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT045262225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist