Most Relevant Information
Provider Data
| NPI Number: | 1003415464 |
| Provider Name: | KIM B JACKSON |
| Entity Type: | Individual |
| Taxonomy Code: | 225700000X |
| Specialty: | Massage Therapist |
| License Number: | 028858 |
Most Important Dates
| Enumeration Date: | 10/18/2020 |
| Last Updated: | 10/18/2020 |
Provider Practice Location
29 GLEN COVE AVE STE 212
GLEN COVE
NY
115422831
Practice Location Phone/Fax
| Phone: | 5163847670 |
| Fax: |
Provider Mailing Location
1360 C ST
ELMONT
NY
110033816
Provider Mailing Phone/Fax
| Phone: | 5163847670 |
| Fax: |