Healthcare Provider Details

I. General information

NPI: 1104055318
Provider Name (Legal Business Name): MARIA TERESA JACKSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 WASHINGTON STREET 210
LAS VEGAS NV
89128
US

IV. Provider business mailing address

929 ALLURE DR
LAS VEGAS NV
89128-2024
US

V. Phone/Fax

Practice location:
  • Phone: 702-220-3325
  • Fax:
Mailing address:
  • Phone: 702-769-8343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2026
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: