Provider Demographics
NPI:1639520380
Name:JACKSON, HEATHER DANIELLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DANIELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DANIELLE
Other - Last Name:DRAGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3301 SUNDOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-8032
Mailing Address - Country:US
Mailing Address - Phone:940-387-3700
Mailing Address - Fax:940-488-4513
Practice Address - Street 1:212 BOLIVAR ST STE 100
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:TX
Practice Address - Zip Code:76266-9775
Practice Address - Country:US
Practice Address - Phone:940-387-7601
Practice Address - Fax:940-257-6200
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5193225100000X
TX1324782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200650100AMedicaid
OK524397ZWAJMedicare PIN