Provider Demographics
NPI:1669640017
Name:JACKSON, ANNE (PT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 35TH LN
Mailing Address - Street 2:STE 100
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6521
Mailing Address - Country:US
Mailing Address - Phone:772-569-2330
Mailing Address - Fax:772-569-2630
Practice Address - Street 1:1155 35TH LN
Practice Address - Street 2:STE 100
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6521
Practice Address - Country:US
Practice Address - Phone:772-569-2330
Practice Address - Fax:772-569-2630
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC4963OtherSC 4963