Provider Demographics
NPI:1750055299
Name:JACKSON, HAILEY NICOLE
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 GILMER ST STE B
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-4378
Mailing Address - Country:US
Mailing Address - Phone:903-962-2600
Mailing Address - Fax:
Practice Address - Street 1:1067 GILMER ST STE B
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4378
Practice Address - Country:US
Practice Address - Phone:903-962-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-08
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4976225100000X
TXPT4976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist