Provider Demographics
NPI:1417297714
Name:JACKSON, YVONNE DENISE (PT)
Entity Type:Individual
Prefix:DR
First Name:YVONNE
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:YVONNE
Other - Middle Name:DENISE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1000 OAKLAND DR FL 3
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1282
Mailing Address - Country:US
Mailing Address - Phone:269-387-7232
Mailing Address - Fax:269-387-7026
Practice Address - Street 1:1000 OAKLAND DR FL 3
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-387-7232
Practice Address - Fax:269-387-7026
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X
MI5501004524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics