Provider Demographics
NPI:1699058008
Name:JACKSON, MICHELLE A
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
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 1:355 KINGBIRD CIR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-5698
Mailing Address - Country:US
Mailing Address - Phone:919-606-6400
Mailing Address - Fax:
Practice Address - Street 1:355 KINGBIRD CIR
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-5698
Practice Address - Country:US
Practice Address - Phone:919-606-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005694225X00000X
FL14246225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0005694OtherCO DEPT OF REGULATION