Provider Demographics
NPI:1437633146
Name:JACKSON, CAROLINE (PTA)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9534
Mailing Address - Country:US
Mailing Address - Phone:407-406-0629
Mailing Address - Fax:
Practice Address - Street 1:291 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9534
Practice Address - Country:US
Practice Address - Phone:407-406-0629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant