MEDICARE: MRS. MARY ANN 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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1528207180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ANN JACKSON NCTMB

Provider Business Mailing Address
First Line	:	28000 HILLER ST
Second Line	:
City	:	HARRISON TOWNSHIP
State	:	MI
Zip	:	48045-2622
Country	:	US
Telephone Number	:	586-206-0348
Fax Number	:

Provider Business Practice Location Address
First Line	:	28000 HILLER ST
Second Line	:
City	:	HARRISON TOWNSHIP
State	:	MI
Zip	:	48045-2622
Country	:	US
Telephone Number	:	586-206-0348
Fax Number	:

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

Provider Enumeration Date	:	02/05/2009
Last Update Date	:	02/05/2009

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