Provider Demographics
NPI:1033523543
Name:JACKSON, JEREMY HEATH (LAT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:HEATH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 REDFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77503-2139
Mailing Address - Country:US
Mailing Address - Phone:713-548-3409
Mailing Address - Fax:
Practice Address - Street 1:3107 REDFIELD DR
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77503-2139
Practice Address - Country:US
Practice Address - Phone:713-548-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT31352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer