Provider Demographics
NPI:1821210907
Name:JACKSON, MATILDA NELMS (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MATILDA
Middle Name:NELMS
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 1:136 KENDALL PALMER RD
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8200
Mailing Address - Country:US
Mailing Address - Phone:912-538-9832
Mailing Address - Fax:
Practice Address - Street 1:136 KENDALL PALMER RD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8200
Practice Address - Country:US
Practice Address - Phone:912-538-9832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000664225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000664OtherPTA