Provider Demographics
NPI:1225124712
Name:JACKSON, OLYMPHIA ANECIA (MSPT)
Entity Type:Individual
Prefix:
First Name:OLYMPHIA
Middle Name:ANECIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6867
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30154-0032
Mailing Address - Country:US
Mailing Address - Phone:678-715-1544
Mailing Address - Fax:
Practice Address - Street 1:4352 MISSOULA PL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8608
Practice Address - Country:US
Practice Address - Phone:678-715-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0075802251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty