Provider Demographics
NPI:1720513997
Name:JACKSON, CHRISTOPHER AINSLEY NALLY (LMT)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:AINSLEY NALLY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 WREN WAY
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-8330
Mailing Address - Country:US
Mailing Address - Phone:302-525-6808
Mailing Address - Fax:
Practice Address - Street 1:124 WREN WAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-8330
Practice Address - Country:US
Practice Address - Phone:302-525-6808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0004504225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist