Provider Demographics
NPI:1811466469
Name:JACKSON, SONNI LEE (LMT)
Entity type:Individual
Prefix:MISS
First Name:SONNI
Middle Name:LEE
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 1:171 UTE WAY
Mailing Address - Street 2:
Mailing Address - City:SILT
Mailing Address - State:CO
Mailing Address - Zip Code:81652-9580
Mailing Address - Country:US
Mailing Address - Phone:970-618-7537
Mailing Address - Fax:
Practice Address - Street 1:151 E CLUBHOUSE DR
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:CO
Practice Address - Zip Code:81647-9424
Practice Address - Country:US
Practice Address - Phone:970-618-7537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0011121225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty