Provider Demographics
NPI:1669668612
Name:JACKSON, NINA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:MARIE
Other - Last Name:PARSONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:925 OAK TREE LN
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-4640
Mailing Address - Country:US
Mailing Address - Phone:540-433-0811
Mailing Address - Fax:540-434-2404
Practice Address - Street 1:220 RESERVOIR ST
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-4321
Practice Address - Country:US
Practice Address - Phone:540-434-9267
Practice Address - Fax:540-434-2404
Is Sole Proprietor?:No
Enumeration Date:2007-09-22
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist