Healthcare Provider Details

I. General information

NPI: 1356628325
Provider Name (Legal Business Name): JACKIE WILSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 N RANGE AVE SUITE B
DENHAM SPRINGS LA
70726-2407
US

IV. Provider business mailing address

1019 N RANGE AVE SUITE B
DENHAM SPRINGS LA
70726-2407
US

V. Phone/Fax

Practice location:
  • Phone: 225-791-8154
  • Fax: 225-791-8152
Mailing address:
  • Phone: 225-791-8154
  • Fax: 225-791-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number1169
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1169
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: