Provider Demographics
NPI:1588246151
Name:JACKSON, KRYSTAL NICOLE (LMT, CHHP)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT, CHHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8342 WHITE MULBERRY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8342 WHITE MULBERRY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-5792
Practice Address - Country:US
Practice Address - Phone:210-556-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT133922225700000X
175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No175F00000XOther Service ProvidersNaturopath