Provider Demographics
NPI:1992023030
Name:JACKSON, LISA (LMT, PT, AS, CHHC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT, PT, AS, CHHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 SW 8TH AVE # B-9
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1888
Mailing Address - Country:US
Mailing Address - Phone:352-222-5381
Mailing Address - Fax:
Practice Address - Street 1:7200 SW 8TH AVE APT 9
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1883
Practice Address - Country:US
Practice Address - Phone:352-222-5381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA45132225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist