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General NPI Number Information
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NPI Number | 1376871103
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Entity Type | Individual
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Provider Name | TONI M. JACKSON NCTMB
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Gender | Female
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Dates
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Enumeration Date | 12/07/2009
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Last Update Date | 02/25/2021
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Provider Practice Location Address
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Address Line | 4806 STATE ST HOME OFFICE
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62205-1355
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Country | US
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Telephone | 618-225-2777
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Fax |
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Provider Business Mailing Address
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Address Line | 4806 STATE ST HOME OFFICE
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62205-1355
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Country | US
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Telephone | 618-271-6247
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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 | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225400000X
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Taxonomy Name | Rehabilitation Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 226000000X
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Taxonomy Name | Recreational Therapist Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 226300000X
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Taxonomy Name | Kinesiotherapist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 2005015267
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License Number State | MO
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