Provider Demographics
NPI:1073104089
Name:DR. BRANDIE JACKSON, LLC
Entity Type:Organization
Organization Name:DR. BRANDIE JACKSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDIE
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:TENA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, CLT
Authorized Official - Phone:757-707-0945
Mailing Address - Street 1:3902 ROCHAMBEAU DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-6620
Mailing Address - Country:US
Mailing Address - Phone:757-707-0945
Mailing Address - Fax:
Practice Address - Street 1:3902 ROCHAMBEAU DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-6620
Practice Address - Country:US
Practice Address - Phone:757-707-0945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health