Provider Demographics
NPI:1265195432
Name:JACKSON, AMBER BROOKE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:BROOKE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:WV
Mailing Address - Zip Code:25878-0155
Mailing Address - Country:US
Mailing Address - Phone:304-894-4875
Mailing Address - Fax:
Practice Address - Street 1:106 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SOPHIA
Practice Address - State:WV
Practice Address - Zip Code:25921-1627
Practice Address - Country:US
Practice Address - Phone:304-894-4875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist