Provider Demographics
NPI:1063236115
Name:JACKSON, JASMINE CEDRA DENISE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:CEDRA DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 MCKENDIMEN RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2017
Mailing Address - Country:US
Mailing Address - Phone:315-247-6523
Mailing Address - Fax:
Practice Address - Street 1:133 JACKSON RD STE B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9234
Practice Address - Country:US
Practice Address - Phone:315-247-6523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01507400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist