Provider Demographics
NPI:1093130726
Name:JACKSON, KIMBERLY DAWN (MPT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:JACKSON
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4917
Mailing Address - Fax:
Practice Address - Street 1:801 W BARBEE CHAPEL RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-8188
Practice Address - Country:US
Practice Address - Phone:919-385-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP2567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist