Provider Demographics
NPI:1417275645
Name:JACKSON, ROXANNE (MPT)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 145TH AVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-8826
Mailing Address - Country:US
Mailing Address - Phone:563-608-2061
Mailing Address - Fax:563-927-8138
Practice Address - Street 1:1953 145TH AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-8826
Practice Address - Country:US
Practice Address - Phone:563-608-2061
Practice Address - Fax:563-927-8138
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist