Provider Demographics
NPI:1811371024
Name:BOTTOMS, JACKIE CHAD (LPTA)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:CHAD
Last Name:BOTTOMS
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 WOODMONT DR
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-6109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 JOHN ALDRIDGE DR
Practice Address - Street 2:
Practice Address - City:TUSCUMBIA
Practice Address - State:AL
Practice Address - Zip Code:35674-3000
Practice Address - Country:US
Practice Address - Phone:256-383-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA7594225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant