Provider Demographics
NPI:1366057218
Name:JACKSON, NADINE A
Entity type:Individual
Prefix:
First Name:NADINE
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 1:4335 VINELAND AVE APT 222
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91602-3430
Mailing Address - Country:US
Mailing Address - Phone:617-272-5294
Mailing Address - Fax:
Practice Address - Street 1:4335 VINELAND AVE APT 222
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91602-3430
Practice Address - Country:US
Practice Address - Phone:617-272-5294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78135225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist