Provider Demographics
NPI:1467504365
Name:JACKSON, MARK FRANKLIN (PT, DPT, MPS, OCS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FRANKLIN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT, DPT, MPS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1109
Mailing Address - Country:US
Mailing Address - Phone:607-423-7509
Mailing Address - Fax:
Practice Address - Street 1:10 BRENTWOOD DR
Practice Address - Street 2:SUITE A
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1865
Practice Address - Country:US
Practice Address - Phone:607-274-4159
Practice Address - Fax:607-274-4675
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000142682OtherEXCELLUS BCBS
NY7475387OtherAETNA US HEALTHCARE
NY4123843OtherMVP
NY7475387OtherAETNA US HEALTHCARE