Provider Demographics
NPI:1336822428
Name:JACKSON, ALAIN JEANINE
Entity type:Individual
Prefix:
First Name:ALAIN
Middle Name:JEANINE
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 1:2261 E DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-6717
Mailing Address - Country:US
Mailing Address - Phone:480-540-3919
Mailing Address - Fax:
Practice Address - Street 1:2261 E DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-6717
Practice Address - Country:US
Practice Address - Phone:480-540-3919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist