Provider Demographics
NPI:1407201437
Name:JACKSON, CHAZERAY MONTEYA (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHAZERAY
Middle Name:MONTEYA
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 KENSINGTON PL APT B
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2393
Mailing Address - Country:US
Mailing Address - Phone:828-275-6688
Mailing Address - Fax:
Practice Address - Street 1:1301 KENSINGTON PLACE APT B
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2393
Practice Address - Country:US
Practice Address - Phone:828-275-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5816225200000X
VA2306604367225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant