Provider Demographics
NPI:1336107408
Name:JACKSON, DEBORAH A (PHD,PT, OCS,CMP, ATC)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD,PT, OCS,CMP, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W TOWN PL
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3101
Mailing Address - Country:US
Mailing Address - Phone:904-342-5262
Mailing Address - Fax:904-217-3580
Practice Address - Street 1:319 W TOWN PL
Practice Address - Street 2:SUITE 5
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3101
Practice Address - Country:US
Practice Address - Phone:904-342-5262
Practice Address - Fax:904-217-3580
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GE918ZOtherMEDICARE
Y5614OtherBCBS