Provider Demographics
NPI:1790979292
Name:JACKSON, THOMAS EUGENE (PT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EUGENE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3607
Mailing Address - Country:US
Mailing Address - Phone:323-255-9263
Mailing Address - Fax:
Practice Address - Street 1:830 S. CITRUS AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702
Practice Address - Country:US
Practice Address - Phone:626-339-6514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist