Healthcare Provider Details

I. General information

NPI: 1124614300
Provider Name (Legal Business Name): NICOLE MARIE JACKSON CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE JACKSON

II. Dates (important events)

Enumeration Date: 12/12/2020
Last Update Date: 12/12/2020
Certification Date: 12/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4728 MONUMENT DR
SACRAMENTO CA
95842-3612
US

IV. Provider business mailing address

PO BOX 188904
SACRAMENTO CA
95818-8904
US

V. Phone/Fax

Practice location:
  • Phone: 916-420-4306
  • Fax:
Mailing address:
  • Phone: 916-420-4306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number80148
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: