Provider Demographics
NPI:1710042569
Name:JACKSON, WILLIAM L (PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 BUFFALO RD
Mailing Address - Street 2:BLDG. 100C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1360
Mailing Address - Country:US
Mailing Address - Phone:585-247-0080
Mailing Address - Fax:585-426-7952
Practice Address - Street 1:2300 BUFFALO RD
Practice Address - Street 2:BLDG. 100C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1360
Practice Address - Country:US
Practice Address - Phone:585-247-0080
Practice Address - Fax:585-426-7952
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100169FTOtherPC
NY7740268OtherAETNA
NY100169FTOtherPC