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General NPI Number Information
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NPI Number | 1003415464
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Entity Type | Individual
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Provider Name | KIM B JACKSON
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Gender | Female
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Dates
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Enumeration Date | 10/18/2020
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Last Update Date | 10/18/2020
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Provider Practice Location Address
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Address Line | 29 GLEN COVE AVE STE 212
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City | GLEN COVE
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State | NY
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Zip | 11542-2831
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Country | US
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Telephone | 516-384-7670
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Fax |
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Provider Business Mailing Address
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Address Line | 1360 C ST
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City | ELMONT
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State | NY
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Zip | 11003-3816
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Country | US
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Telephone | 516-384-7670
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 028858
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License Number State | NY
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