Provider Demographics
NPI:1689866857
Name:JACKSON, RONALD ELIOT (LICENSED PTA)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:ELIOT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LICENSED PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11615 BASKET XING
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-3375
Mailing Address - Country:US
Mailing Address - Phone:210-360-0968
Mailing Address - Fax:
Practice Address - Street 1:11615 BASKET XING
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-3375
Practice Address - Country:US
Practice Address - Phone:210-360-0968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2063260225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant