Provider Demographics
NPI:1487097333
Name:JACKSON, DANNY L (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MR
First Name:DANNY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 GRIFFITH ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1503
Mailing Address - Country:US
Mailing Address - Phone:269-832-4644
Mailing Address - Fax:
Practice Address - Street 1:1214 GRIFFITH ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1503
Practice Address - Country:US
Practice Address - Phone:269-832-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000296225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist