Provider Demographics
NPI:1174725642
Name:JACKSON, KATHLEEN M (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 NORTH HILL DR
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2610
Mailing Address - Country:US
Mailing Address - Phone:540-341-1922
Mailing Address - Fax:540-341-1923
Practice Address - Street 1:40 NORTH HILL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2610
Practice Address - Country:US
Practice Address - Phone:540-341-1922
Practice Address - Fax:540-341-1923
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194042OtherANTHEM
VA013933B90Medicare UPIN
VAC08090Medicare PIN