Healthcare Provider Details

I. General information

NPI: 1922359470
Provider Name (Legal Business Name): JENNIFER S JACKSON D.AC., MSOM, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W MAIN RD
MIDDLETOWN RI
02842-4937
US

IV. Provider business mailing address

126 W MAIN RD
MIDDLETOWN RI
02842-4937
US

V. Phone/Fax

Practice location:
  • Phone: 401-862-4894
  • Fax:
Mailing address:
  • Phone: 401-862-4894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDA00395
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: