1679757165 NPI number — MS. BRIDIGET L JACKSON-GROSS MASSAGE THERAPIST

Table of content: MS. BRIDIGET L JACKSON-GROSS MASSAGE THERAPIST (NPI 1679757165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679757165 NPI number — MS. BRIDIGET L JACKSON-GROSS MASSAGE THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON-GROSS
Provider First Name:
BRIDIGET
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MASSAGE THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679757165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4407 SHERIDAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-3513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-893-7233
Provider Business Mailing Address Fax Number:
954-491-6862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
570 OCEAN DR
Provider Second Line Business Practice Location Address:
501
Provider Business Practice Location Address City Name:
JUNO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33408-1952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-491-2225
Provider Business Practice Location Address Fax Number:
954-491-6862
Provider Enumeration Date:
12/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA 47120 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MA 47120 . This is a "MASSAGE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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