Provider Demographics
NPI:1083163521
Name:JACKSON, BRANDON TRAVON (DPT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:TRAVON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3360 OHARA DR N
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-3832
Mailing Address - Country:US
Mailing Address - Phone:478-216-8765
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CULLOWHEE
Practice Address - State:NC
Practice Address - Zip Code:28723-9646
Practice Address - Country:US
Practice Address - Phone:478-361-8736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
GAPT015749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program