Provider Demographics
NPI:1497183750
Name:JACKSON, AISHA
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:
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 1:812 TAYLOR ST NE APT 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2012
Mailing Address - Country:US
Mailing Address - Phone:202-321-5265
Mailing Address - Fax:202-629-4647
Practice Address - Street 1:1200 1ST ST NE FL 9
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7953
Practice Address - Country:US
Practice Address - Phone:202-321-5265
Practice Address - Fax:202-629-4647
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT26442251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics