Provider Demographics
NPI:1679175921
Name:JACKSON, PATIENCE (RELAXATION THERAPIST)
Entity type:Individual
Prefix:
First Name:PATIENCE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RELAXATION THERAPIST
Other - Prefix:
Other - First Name:PATIENCE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RELAXATION THERAPIST
Mailing Address - Street 1:600 W 6TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3684
Mailing Address - Country:US
Mailing Address - Phone:805-221-0208
Mailing Address - Fax:
Practice Address - Street 1:600 W 6TH ST FL 4
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3684
Practice Address - Country:US
Practice Address - Phone:805-221-0208
Practice Address - Fax:469-754-0469
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174H00000XOther Service ProvidersHealth Educator
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program