Provider Demographics
NPI:1487846366
Name:JACKSON, WILLIAM BRADLEY (PTA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADLEY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1179
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 DIVISION ST
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1179
Practice Address - Country:US
Practice Address - Phone:413-528-4289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8151225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant