Provider Demographics
NPI:1134518343
Name:JACKSON, HANNA MAE (PTA)
Entity Type:Individual
Prefix:
First Name:HANNA
Middle Name:MAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3824 S CARRIER PKWY
Mailing Address - Street 2:470
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6644
Mailing Address - Country:US
Mailing Address - Phone:972-262-9972
Mailing Address - Fax:972-262-9986
Practice Address - Street 1:3824 S CARRIER PKWY
Practice Address - Street 2:470
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6644
Practice Address - Country:US
Practice Address - Phone:972-262-9972
Practice Address - Fax:972-262-9986
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096038225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant