Provider Demographics
NPI:1679757165
Name:JACKSON-GROSS, BRIDIGET L (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MS
First Name:BRIDIGET
Middle Name:L
Last Name:JACKSON-GROSS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3513
Mailing Address - Country:US
Mailing Address - Phone:954-893-7233
Mailing Address - Fax:954-491-6862
Practice Address - Street 1:570 OCEAN DR
Practice Address - Street 2:501
Practice Address - City:JUNO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-1952
Practice Address - Country:US
Practice Address - Phone:954-491-2225
Practice Address - Fax:954-491-6862
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 47120225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 47120OtherMASSAGE LICENSE