Provider Demographics
NPI:1639339443
Name:JACKSON, PAUL CHARLES (PTA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CHARLES
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 1:5446 S SAN PAULO AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-9356
Mailing Address - Country:US
Mailing Address - Phone:520-378-0744
Mailing Address - Fax:
Practice Address - Street 1:660 S CORONADO DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-3386
Practice Address - Country:US
Practice Address - Phone:520-459-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7580A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant