MEDICARE: JOSIE JACKSON LMT

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	MA100634	FL

General Provider Information

NPI Number	:	1346083284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSIE JACKSON LMT

Provider Business Mailing Address
First Line	:	5706 BLACKTHORN RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-2008
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5706 BLACKTHORN RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-2008
Country	:	US
Telephone Number	:	210-999-0960
Fax Number	:

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

Provider Enumeration Date	:	06/18/2024
Last Update Date	:	06/28/2024

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