MEDICARE: DAVID EDWARD JACKSON III C.M.T.

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

General Provider Information

NPI Number	:	1275711350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID EDWARD JACKSON III C.M.T.

Provider Business Mailing Address
First Line	:	3321 E 35TH AVE
Second Line	:
City	:	LAKE STATION
State	:	IN
Zip	:	46405-3016
Country	:	US
Telephone Number	:	219-714-4100
Fax Number	:

Provider Business Practice Location Address
First Line	:	3321 E 35TH AVE
Second Line	:
City	:	LAKE STATION
State	:	IN
Zip	:	46405-3016
Country	:	US
Telephone Number	:	219-714-4100
Fax Number	:

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

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	01/31/2008

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