Provider Demographics
NPI:1235306143
Name:JACKSON, JOSEPH (RPT)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-5510
Mailing Address - Country:US
Mailing Address - Phone:310-631-8703
Mailing Address - Fax:562-591-1422
Practice Address - Street 1:15640 S NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4016
Practice Address - Country:US
Practice Address - Phone:310-631-8703
Practice Address - Fax:310-763-0400
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT5788225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist