Provider Demographics
NPI:1922191295
Name:JACKSON, LINDA J (LIC AC)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MAIN ST
Mailing Address - Street 2:BOX 62
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1307
Mailing Address - Country:US
Mailing Address - Phone:413-528-3514
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:BOX 62
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1307
Practice Address - Country:US
Practice Address - Phone:413-528-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA598171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist