Provider Demographics
NPI:1578966222
Name:JACKSON, WHITNEY REAGAN (DPT)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:REAGAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1151
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01090-1151
Mailing Address - Country:US
Mailing Address - Phone:413-582-0330
Mailing Address - Fax:413-586-1068
Practice Address - Street 1:766 N KING ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-1142
Practice Address - Country:US
Practice Address - Phone:413-582-0330
Practice Address - Fax:413-586-1068
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist