Provider Demographics
NPI:1689107542
Name:JACKSON, JILLYN (PTA)
Entity Type:Individual
Prefix:
First Name:JILLYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 E 1300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1949
Mailing Address - Country:US
Mailing Address - Phone:801-641-2494
Mailing Address - Fax:
Practice Address - Street 1:1256 E 1300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-1949
Practice Address - Country:US
Practice Address - Phone:801-641-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT284914-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant