=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740467414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INGRID ANN JACKSON LMBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2008
-----------------------------------------------------
Last Update Date | 01/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2698 CONNESTEE TRL
-----------------------------------------------------
City | BREVARD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28712-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-877-2090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2698 CONNESTEE TRL
-----------------------------------------------------
City | BREVARD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28712-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-877-2090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 6965
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------