Provider Demographics
NPI:1659784320
Name:JACKSON, NATASHA MONIQUE (DPT)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:MONIQUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 PROSPERITY FARMS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3462
Mailing Address - Country:US
Mailing Address - Phone:561-432-0111
Mailing Address - Fax:
Practice Address - Street 1:11000 PROSPERITY FARMS RD STE 203
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-3462
Practice Address - Country:US
Practice Address - Phone:561-432-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 29279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist