Provider Demographics
NPI:1952187882
Name:JACKSON, CORRINE R (LMT)
Entity Type:Individual
Prefix:
First Name:CORRINE
Middle Name:R
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 1:23 NEW SOUTHGATE RD LOWR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1809
Mailing Address - Country:US
Mailing Address - Phone:716-310-4070
Mailing Address - Fax:
Practice Address - Street 1:474 NIAGARA FALLS BLVD STE 4
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223-2647
Practice Address - Country:US
Practice Address - Phone:716-235-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030743225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist