Healthcare Provider Details

I. General information

NPI: 1477461861
Provider Name (Legal Business Name): AMANDA RITA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 W SHAW AVE STE A
FRESNO CA
93711-3612
US

IV. Provider business mailing address

1890 CENTENNIAL DR APT 114
HANFORD CA
93230-9378
US

V. Phone/Fax

Practice location:
  • Phone: 559-521-3321
  • Fax:
Mailing address:
  • Phone: 559-521-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number87507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: