Provider Demographics
NPI:1922837681
Name:JACKSON, KYLE G (LMBT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3739 COLORADO DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-2105
Mailing Address - Country:US
Mailing Address - Phone:910-568-2058
Mailing Address - Fax:
Practice Address - Street 1:5780 RAMSEY ST STE 105
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1414
Practice Address - Country:US
Practice Address - Phone:910-488-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19362225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist