Provider Demographics
NPI:1033597372
Name:JACKSON, CARISSA (DPT)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6409 S VINEWOOD ST
Mailing Address - Street 2:APT 1-308
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-1812
Mailing Address - Country:US
Mailing Address - Phone:575-644-5561
Mailing Address - Fax:
Practice Address - Street 1:6409 S VINEWOOD ST
Practice Address - Street 2:APT 1-308
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-1812
Practice Address - Country:US
Practice Address - Phone:575-644-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTLP.0000009225100000X
COPTL.0013481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist