Provider Demographics
NPI:1720541550
Name:JACKSON, DOMINIC A (DPT)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16210 BRAESGATE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-4850
Mailing Address - Country:US
Mailing Address - Phone:408-568-1586
Mailing Address - Fax:
Practice Address - Street 1:16210 BRAESGATE DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-4850
Practice Address - Country:US
Practice Address - Phone:408-568-1586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1315070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist