Provider Demographics
NPI:1386106326
Name:JACKSON, JESSICA MARIE (ATC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAIN ST APT 217
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-3528
Mailing Address - Country:US
Mailing Address - Phone:817-422-6403
Mailing Address - Fax:
Practice Address - Street 1:120 MAIN ST APT 217
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-3528
Practice Address - Country:US
Practice Address - Phone:817-422-6403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer