Provider Demographics
NPI:1316406747
Name:JACKSON, BRANDI (DPT)
Entity Type:Individual
Prefix:
First Name:BRANDI
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:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2572 E SOUTH WEBER DR STE 5
Practice Address - Street 2:
Practice Address - City:SOUTH WEBER
Practice Address - State:UT
Practice Address - Zip Code:84405-9550
Practice Address - Country:US
Practice Address - Phone:801-479-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11189504-2401OtherPT LICENSE