Provider Demographics
NPI:1659039824
Name:JACKSON, DEBORAH ANN (PTA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:KLITZING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:934 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-2149
Mailing Address - Country:US
Mailing Address - Phone:618-267-0756
Mailing Address - Fax:
Practice Address - Street 1:1525 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-3162
Practice Address - Country:US
Practice Address - Phone:815-672-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty