Provider Demographics
NPI:1275966731
Name:JACKSON, HOLLY (DPT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 MAIN DR STE B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6364
Mailing Address - Country:US
Mailing Address - Phone:479-856-6400
Mailing Address - Fax:479-856-6623
Practice Address - Street 1:3801 MAIN DR STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6364
Practice Address - Country:US
Practice Address - Phone:479-856-6400
Practice Address - Fax:479-856-6623
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist