Provider Demographics
NPI:1730279100
Name:JACKSON, ARLYN RIVERA (MPT)
Entity Type:Individual
Prefix:
First Name:ARLYN
Middle Name:RIVERA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-1413
Mailing Address - Country:US
Mailing Address - Phone:904-377-5559
Mailing Address - Fax:
Practice Address - Street 1:111 NATURE WALK PARKWAY STE 101
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:904-230-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist