Provider Demographics
NPI:1063667053
Name:JACKSON, HENRY (PT)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 TILDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-4819
Mailing Address - Country:US
Mailing Address - Phone:718-451-2905
Mailing Address - Fax:718-451-2577
Practice Address - Street 1:5605 TILDEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-4819
Practice Address - Country:US
Practice Address - Phone:718-451-2905
Practice Address - Fax:718-451-2577
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist