Provider Demographics
NPI:1205107828
Name:JACKSON, MARYAH V (LMP)
Entity type:Individual
Prefix:
First Name:MARYAH
Middle Name:V
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S MAIN ST # 8062
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5635
Mailing Address - Country:US
Mailing Address - Phone:406-696-3908
Mailing Address - Fax:
Practice Address - Street 1:1001 S MAIN ST # 8062
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5635
Practice Address - Country:US
Practice Address - Phone:406-696-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5952225700000X
OR18071225700000X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist