Healthcare Provider Details

I. General information

NPI: 1639966112
Provider Name (Legal Business Name): KIM JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 UNIVERSITY DR.
COLLEGEDALE TN
37315
US

IV. Provider business mailing address

2008 TOMBRAS AVE
CHATTANOOGA TN
37412-2730
US

V. Phone/Fax

Practice location:
  • Phone: 423-396-2100
  • Fax:
Mailing address:
  • Phone: 423-827-9394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6973
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: