Phyliss L Jackson, LCMT,HE

Primary specialty

Massage TherapistTaxonomy code 225700000X

License

80744 Issued in CA

Practice address

1 Adventist Health Way
Roseville, CA 95661-3266

Phone

(916) 406-0177

NPI assigned

Feb 27, 2020

Last updated

Feb 27, 2020By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1582761600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1582761600000",
    "number": "1326672494",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2201 ARENA BLVD APT 7106",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958347940",
            "telephone_number": "916-706-9892"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 ADVENTIST HEALTH WAY",
            "city": "ROSEVILLE",
            "state": "CA",
            "postal_code": "956613266",
            "telephone_number": "916-406-0177"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "PHYLISS",
        "middle_name": "L",
        "credential": "LCMT,HE",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-02-27",
        "last_updated": "2020-02-27",
        "certification_date": "2020-02-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225700000X",
            "taxonomy_group": "",
            "desc": "Massage Therapist",
            "state": "CA",
            "license": "80744",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "B4915041",
            "state": "CA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jacksopl@ah.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "1 Adventist Health Way",
            "city": "Roseville",
            "state": "CA",
            "country_code": "US",
            "postal_code": "956613266",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Stephanie Jacks
• Christine Jackson
• Christine Diane Jackson, O.T.
• Diane Jackson, MFT
• Gwenecia Jackson
• Rhonette Estelle Jackson, M.D.
• Richard Fredrick Jackson, DD.S.
• Roland Ignatius Jackson Jr., PT
• T Theresa Jackson, MT-BC
• Jacob D Kelly DDS, Inc.

• Massage Therapist in Roseville, CA
• Providers in Roseville, CA by specialty
• Massage Therapist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.