Provider Demographics
NPI:1194138297
Name:JACKMAN, KATHLEEN (LMT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LOWER LAS COLONIAS RD
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-7461
Mailing Address - Country:US
Mailing Address - Phone:575-770-2001
Mailing Address - Fax:
Practice Address - Street 1:98 HIGHWAY 150
Practice Address - Street 2:SUITE 11
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529-7461
Practice Address - Country:US
Practice Address - Phone:575-770-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3484225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist