=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811466469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SONNI LEE JACKSON LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2018
-----------------------------------------------------
Last Update Date | 11/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 E CLUBHOUSE DR
-----------------------------------------------------
City | NEW CASTLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81647-9424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-618-7537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 171 UTE WAY
-----------------------------------------------------
City | SILT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81652-9580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-618-7537
-----------------------------------------------------
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 | MT.0011121
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------