Provider Demographics
NPI:1306000864
Name:JACKSON, KITARSHYI MULDROW (PT)
Entity Type:Individual
Prefix:
First Name:KITARSHYI
Middle Name:MULDROW
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 LONG PINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27976-9611
Mailing Address - Country:US
Mailing Address - Phone:252-771-8305
Mailing Address - Fax:
Practice Address - Street 1:1075 US HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-7628
Practice Address - Country:US
Practice Address - Phone:252-338-3975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7927225100000X
CA20501225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist