Provider Demographics
NPI:1417267592
Name:JACKSON PHYSICAL THERAPY AND STUDIO
Entity Type:Organization
Organization Name:JACKSON PHYSICAL THERAPY AND STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:HOSIE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT, CPI
Authorized Official - Phone:949-307-7914
Mailing Address - Street 1:11 BANEBERRY
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2147
Mailing Address - Country:US
Mailing Address - Phone:949-307-7914
Mailing Address - Fax:949-716-9224
Practice Address - Street 1:1100 S COAST HWY
Practice Address - Street 2:SUITE 301 B
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2968
Practice Address - Country:US
Practice Address - Phone:949-307-7914
Practice Address - Fax:949-716-9224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 202232251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty