Provider Demographics
NPI:1164241345
Name:JACKSON, NICKI ANGELYN (LMT)
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:ANGELYN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 FREEBIRD LN UNIT 108
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-5635
Mailing Address - Country:US
Mailing Address - Phone:310-600-8163
Mailing Address - Fax:
Practice Address - Street 1:5816 FREEBIRD LN UNIT 108
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:CA
Practice Address - Zip Code:91377-5635
Practice Address - Country:US
Practice Address - Phone:310-600-8163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT29417225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist