Provider Demographics
NPI:1376277905
Name:DAVENPORT, JACKSON D (DPT)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:D
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:9950 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4028
Practice Address - Country:US
Practice Address - Phone:219-934-2840
Practice Address - Fax:219-934-2841
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN05014727A225100000X
IL070026760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist