MEDICARE: TONI M. JACKSON NCTMB

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	171000000X	Military Health Care Provider
2	225400000X	Rehabilitation Practitioner
3	226000000X	Recreational Therapist Assistant
4	226300000X	Kinesiotherapist
5	225700000X	Massage Therapist	2005015267	MO

General Provider Information

NPI Number	:	1376871103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONI M. JACKSON NCTMB

Provider Business Mailing Address
First Line	:	4806 STATE ST
Second Line	:	HOME OFFICE
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-1355
Country	:	US
Telephone Number	:	618-271-6247
Fax Number	:

Provider Business Practice Location Address
First Line	:	4806 STATE ST
Second Line	:	HOME OFFICE
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-1355
Country	:	US
Telephone Number	:	618-225-2777
Fax Number	:

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

Provider Enumeration Date	:	12/07/2009
Last Update Date	:	02/25/2021

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