Healthcare Provider Details

I. General information

NPI: 1316783137
Provider Name (Legal Business Name): KRISTINE JACKSON MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 07/02/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27169 CALIFORNIA HIGHWAY 189, SUITE 2
BLUE JAY CA
92317
US

IV. Provider business mailing address

PO BOX 2392
LAKE ARROWHEAD CA
92352-2392
US

V. Phone/Fax

Practice location:
  • Phone: 909-486-9705
  • Fax: 909-323-0215
Mailing address:
  • Phone: 909-486-9648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number94145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: