Provider Demographics
NPI:1366000200
Name:JACKSON, BRIANNA MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
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 1:7075 PECAN GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-2112
Mailing Address - Country:US
Mailing Address - Phone:251-404-9176
Mailing Address - Fax:
Practice Address - Street 1:7721 AIRPORT BLVD STE E120
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-5052
Practice Address - Country:US
Practice Address - Phone:251-631-3680
Practice Address - Fax:251-631-3681
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6660225100000X
ALPTH9345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist