Provider Demographics
NPI:1629766936
Name:JACKSON, DYNEISHA AKEL
Entity Type:Individual
Prefix:
First Name:DYNEISHA
Middle Name:AKEL
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 1:2300 CLEAR CREEK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4985
Mailing Address - Country:US
Mailing Address - Phone:254-554-2637
Mailing Address - Fax:
Practice Address - Street 1:2300 CLEAR CREEK RD STE 102
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4985
Practice Address - Country:US
Practice Address - Phone:254-554-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13667362251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic