Provider Demographics
NPI:1275918401
Name:JACKSON, STEPHEN (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36501 MISSION ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3289
Mailing Address - Country:US
Mailing Address - Phone:225-744-3631
Mailing Address - Fax:225-744-3647
Practice Address - Street 1:36501 MISSION ST
Practice Address - Street 2:SUITE A
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3289
Practice Address - Country:US
Practice Address - Phone:225-744-3631
Practice Address - Fax:225-744-3647
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist