Provider Demographics
NPI:1710177142
Name:JACKSON, CHAD WILLIAM (PT, DPT, OCS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:WILLIAM
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2565
Mailing Address - Country:US
Mailing Address - Phone:660-562-2705
Mailing Address - Fax:660-562-7967
Practice Address - Street 1:822 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2565
Practice Address - Country:US
Practice Address - Phone:660-562-2705
Practice Address - Fax:660-562-7967
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010193792251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic