Provider Demographics
NPI:1659063956
Name:JACKSON, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
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 1:800 HERTEL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1906
Mailing Address - Country:US
Mailing Address - Phone:716-566-5050
Mailing Address - Fax:
Practice Address - Street 1:800 HERTEL AVE STE 101
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1906
Practice Address - Country:US
Practice Address - Phone:716-566-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY051568-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist