Provider Demographics
NPI:1902047954
Name:JACKSON, SUSAN R. RENEE (LMP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN R.
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 N 7TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6305
Mailing Address - Country:US
Mailing Address - Phone:360-790-9195
Mailing Address - Fax:
Practice Address - Street 1:511 N 7TH AVE SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6305
Practice Address - Country:US
Practice Address - Phone:360-790-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60073078225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist