Provider Demographics
NPI:1003511908
Name:DR. KATIE JACKSON'S WOUND, OSTOMY AND FOOTCARE
Entity Type:Organization
Organization Name:DR. KATIE JACKSON'S WOUND, OSTOMY AND FOOTCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:978-821-0842
Mailing Address - Street 1:16 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01473-1132
Mailing Address - Country:US
Mailing Address - Phone:978-821-0842
Mailing Address - Fax:
Practice Address - Street 1:179 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:MA
Practice Address - Zip Code:01543-1614
Practice Address - Country:US
Practice Address - Phone:978-821-0842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Multi-Specialty