Provider Demographics
NPI:1841486289
Name:JACKSON, THERESA Y (LMT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:Y
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 1:1803 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4342
Mailing Address - Country:US
Mailing Address - Phone:904-766-1484
Mailing Address - Fax:904-236-6187
Practice Address - Street 1:1803 BOULEVARD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4342
Practice Address - Country:US
Practice Address - Phone:904-236-4619
Practice Address - Fax:904-236-6187
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48068225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist