Provider Demographics
NPI:1376787705
Name:JACKSON, BRADLEY A (PT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 N LAKESHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4326
Mailing Address - Country:US
Mailing Address - Phone:906-225-5044
Mailing Address - Fax:906-225-5049
Practice Address - Street 1:3135 US HIGHWAY 41 W
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-9494
Practice Address - Country:US
Practice Address - Phone:906-225-5900
Practice Address - Fax:906-225-5939
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP44610009Medicare PIN