Provider Demographics
NPI:1760719694
Name:JACKSON, ASHLEE BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:ASHLEE
Middle Name:BROOKE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-0160
Mailing Address - Country:US
Mailing Address - Phone:606-598-7673
Mailing Address - Fax:
Practice Address - Street 1:376 MANCHESTER SQUARE SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962
Practice Address - Country:US
Practice Address - Phone:606-599-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02403225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant