Provider Demographics
NPI:1467753640
Name:JACKSON, AMY W
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-1149
Mailing Address - Country:US
Mailing Address - Phone:814-643-5724
Mailing Address - Fax:814-643-6085
Practice Address - Street 1:1301 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-1149
Practice Address - Country:US
Practice Address - Phone:814-643-5724
Practice Address - Fax:814-643-6085
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003399L2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics