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General NPI Number Information
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NPI Number | 1174038368
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Entity Type | Individual
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Provider Name | TRAVIS EDWARD JACKSON LMT
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Gender | Male
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Dates
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Enumeration Date | 12/10/2017
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Last Update Date | 12/10/2017
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Provider Practice Location Address
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Address Line | 427 SW 152ND ST UNIT C
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City | BURIEN
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State | WA
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Zip | 98166-2208
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Country | US
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Telephone | 206-787-0502
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Fax | 206-787-0502
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Provider Business Mailing Address
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Address Line | 21609 6TH AVE S
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City | NORMANDY PARK
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State | WA
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Zip | 98198-6114
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Country | US
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Telephone | 206-878-0502
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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 | MA60689794
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License Number State | WA
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