Provider Demographics
NPI:1033365002
Name:JACKSON, KELLY NICOLE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8464 ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-2606
Mailing Address - Country:US
Mailing Address - Phone:402-960-9964
Mailing Address - Fax:402-445-6162
Practice Address - Street 1:2085 N 120TH ST
Practice Address - Street 2:SUITE D8
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3479
Practice Address - Country:US
Practice Address - Phone:402-445-4335
Practice Address - Fax:402-445-6162
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE733225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant