Provider Demographics
NPI:1932943396
Name:JACKSON, CARRIE
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:
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 1:4340 ULUA ST
Mailing Address - Street 2:
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-5378
Mailing Address - Country:US
Mailing Address - Phone:808-346-5388
Mailing Address - Fax:
Practice Address - Street 1:4340 ULUA ST
Practice Address - Street 2:
Practice Address - City:KILAUEA
Practice Address - State:HI
Practice Address - Zip Code:96754-5378
Practice Address - Country:US
Practice Address - Phone:808-346-5388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach