Provider Demographics
NPI:1629349816
Name:JACKSON, SARAH E (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 OLEAN ST
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-2513
Mailing Address - Country:US
Mailing Address - Phone:716-652-3127
Mailing Address - Fax:716-652-3128
Practice Address - Street 1:13 OLEAN ST
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2513
Practice Address - Country:US
Practice Address - Phone:716-652-3127
Practice Address - Fax:716-652-3128
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006150-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant