Provider Demographics
NPI:1417040288
Name:JACKSON, EMILY (PT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W SAGINAW ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-2033
Mailing Address - Country:US
Mailing Address - Phone:517-321-4646
Mailing Address - Fax:517-321-4825
Practice Address - Street 1:1100 W SAGINAW ST STE 2A
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-2033
Practice Address - Country:US
Practice Address - Phone:517-321-4646
Practice Address - Fax:517-321-4825
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30658OtherBCBS
MI236520Medicare ID - Type UnspecifiedMEDICARE