Provider Demographics
NPI:1346765195
Name:JACKSON-RICKETTS, DAMIEN S (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:DAMIEN
Middle Name:S
Last Name:JACKSON-RICKETTS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 PALMS BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3853
Mailing Address - Country:US
Mailing Address - Phone:276-768-7816
Mailing Address - Fax:
Practice Address - Street 1:904 PALMS BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-3853
Practice Address - Country:US
Practice Address - Phone:276-768-7816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA293358OtherPHYSICAL THERAPY LICENSE NUMBER