Provider Demographics
NPI:1326169178
Name:JACKSON, STEVEN (PT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 HARBOR CLIFF WAY UNIT 262
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-2281
Mailing Address - Country:US
Mailing Address - Phone:760-730-5663
Mailing Address - Fax:
Practice Address - Street 1:2530 VISTA WAY STE H
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6174
Practice Address - Country:US
Practice Address - Phone:760-435-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1130326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist