Provider Demographics
NPI:1114441375
Name:JACKSON, MICHAEL FRANK JR (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FRANK
Last Name:JACKSON
Suffix:JR
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 1:121 PARTRIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-6592
Mailing Address - Country:US
Mailing Address - Phone:478-333-3075
Mailing Address - Fax:478-333-3484
Practice Address - Street 1:1806 RUSSELL PKWY STE 1400
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5781
Practice Address - Country:US
Practice Address - Phone:478-235-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist