Provider Demographics
NPI:1952660201
Name:JACKSON, TERISA MARIE (ND)
Entity Type:Individual
Prefix:DR
First Name:TERISA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 KUPULAU DR
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-9349
Mailing Address - Country:US
Mailing Address - Phone:206-393-2566
Mailing Address - Fax:206-319-4603
Practice Address - Street 1:711 KUPULAU DR
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-9349
Practice Address - Country:US
Practice Address - Phone:206-393-2566
Practice Address - Fax:206-319-4603
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIND-249175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath