Provider Demographics
NPI:1821314840
Name:JACKSON, CASEY D (DPT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 FAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:WESTOVER
Mailing Address - State:WV
Mailing Address - Zip Code:26501-4060
Mailing Address - Country:US
Mailing Address - Phone:304-225-5222
Mailing Address - Fax:304-225-5224
Practice Address - Street 1:174 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:JANE LEW
Practice Address - State:WV
Practice Address - Zip Code:26378-9785
Practice Address - Country:US
Practice Address - Phone:304-884-8237
Practice Address - Fax:304-884-8924
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist