Provider Demographics
NPI:1164551826
Name:JACKSON, ASHIYA FAYE (DPT, PCS)
Entity Type:Individual
Prefix:MS
First Name:ASHIYA
Middle Name:FAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 KEZIAH RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1993
Mailing Address - Country:US
Mailing Address - Phone:773-592-6873
Mailing Address - Fax:
Practice Address - Street 1:3205 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2866
Practice Address - Country:US
Practice Address - Phone:704-336-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700109612251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics