Provider Demographics
NPI:1972106839
Name:JACKSON, TINISHA SIMONE (LMT)
Entity type:Individual
Prefix:
First Name:TINISHA
Middle Name:SIMONE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TINISHA
Other - Middle Name:SIMONE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:35357 DRAKESHIRE LN APT 201
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48335-3260
Mailing Address - Country:US
Mailing Address - Phone:248-897-6724
Mailing Address - Fax:
Practice Address - Street 1:35357 DRAKESHIRE LN APT 201
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48335-3260
Practice Address - Country:US
Practice Address - Phone:248-897-6724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010907225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist