Provider Demographics
NPI:1255098869
Name:JACKSON, JUDY ELAINE (LMT)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:ELAINE
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 1:604 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252-5412
Mailing Address - Country:US
Mailing Address - Phone:940-839-9301
Mailing Address - Fax:
Practice Address - Street 1:604 W 11TH ST
Practice Address - Street 2:
Practice Address - City:QUANAH
Practice Address - State:TX
Practice Address - Zip Code:79252-5412
Practice Address - Country:US
Practice Address - Phone:940-839-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT135656225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty