Provider Demographics
NPI:1386288330
Name:JACKSON, TRAVIS AARON (LMBT, NASM-CPT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:AARON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMBT, NASM-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-4121
Mailing Address - Country:US
Mailing Address - Phone:828-772-0719
Mailing Address - Fax:
Practice Address - Street 1:191 CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-1989
Practice Address - Country:US
Practice Address - Phone:828-772-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-03
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4393225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist