Provider Demographics
NPI:1003478181
Name:CLOUSE, JACKSON DAVID
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:DAVID
Last Name:CLOUSE
Suffix:
Gender:M
Credentials:
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 1004
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-1004
Mailing Address - Country:US
Mailing Address - Phone:731-613-2214
Mailing Address - Fax:
Practice Address - Street 1:2060 RHINO CROSSING
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358
Practice Address - Country:US
Practice Address - Phone:731-613-2214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist