Provider Demographics
NPI:1235743287
Name:JACKSON, ELIZABETH JANE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JANE
Other - Last Name:HAYNIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1919 OXMOOR RD # 411
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-3502
Mailing Address - Country:US
Mailing Address - Phone:334-451-5385
Mailing Address - Fax:
Practice Address - Street 1:2241 GREAT ROCK RD
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-2121
Practice Address - Country:US
Practice Address - Phone:334-451-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH9342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist