Provider Demographics
NPI:1548432586
Name:JACKSON, KIMBERLY STEWART (LMT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:STEWART
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:PO BOX 1726
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-1726
Mailing Address - Country:US
Mailing Address - Phone:478-986-0484
Mailing Address - Fax:478-986-0486
Practice Address - Street 1:247 LANA DR
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032-5883
Practice Address - Country:US
Practice Address - Phone:478-986-0484
Practice Address - Fax:478-986-0486
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT001628225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist