Provider Demographics
NPI:1679236871
Name:JACKSON, TY ALAN (PTA)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:ALAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 ROADRUNNER DR
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2451
Mailing Address - Country:US
Mailing Address - Phone:580-775-3227
Mailing Address - Fax:
Practice Address - Street 1:1801 CHUKKA HINA
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-7117
Practice Address - Country:US
Practice Address - Phone:580-920-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3010225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant