Provider Demographics
NPI:1871022061
Name:JACKSON, GEORONIKA (PT)
Entity Type:Individual
Prefix:
First Name:GEORONIKA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26400 KUYKENDAHL RD
Mailing Address - Street 2:SUITE C-180, #113
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77375-2946
Mailing Address - Country:US
Mailing Address - Phone:281-734-2408
Mailing Address - Fax:
Practice Address - Street 1:4806 RIVERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4092
Practice Address - Country:US
Practice Address - Phone:281-499-5808
Practice Address - Fax:281-499-5808
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1289681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist