Provider Demographics
NPI:1467564096
Name:JACKSON, JILL A (PT)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1809
Mailing Address - Country:US
Mailing Address - Phone:815-399-9867
Mailing Address - Fax:
Practice Address - Street 1:4940 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2270
Practice Address - Country:US
Practice Address - Phone:815-227-0081
Practice Address - Fax:815-387-5315
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist