Provider Demographics
NPI:1114330610
Name:JACKSON, ERICA (DPT)
Entity Type:Individual
Prefix:
First Name:ERICA
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 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:7989 BELT LINE RD STE 90
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-5728
Practice Address - Country:US
Practice Address - Phone:972-942-2475
Practice Address - Fax:972-645-0687
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1243858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1243858OtherPHYSICAL THERAPIST - REGULAR LICENSE