MEDICARE: MISTY D JACKSON MASSAGE THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT-05655	AZ

General Provider Information

NPI Number	:	1154280758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY D JACKSON MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	1190 E SHADOW LN
Second Line	:
City	:	HUACHUCA CITY
State	:	AZ
Zip	:	85616-8441
Country	:	US
Telephone Number	:	520-559-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	1190 E SHADOW LN
Second Line	:
City	:	HUACHUCA CITY
State	:	AZ
Zip	:	85616-8441
Country	:	US
Telephone Number	:	520-559-4600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2026
Last Update Date	:	01/19/2026

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