Provider Demographics
NPI:1881039683
Name:JACKSON, DONICA CHIVON (CPTA)
Entity Type:Individual
Prefix:
First Name:DONICA
Middle Name:CHIVON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66106-2842
Mailing Address - Country:US
Mailing Address - Phone:913-406-3044
Mailing Address - Fax:
Practice Address - Street 1:11900 JESSICA LN
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138-2649
Practice Address - Country:US
Practice Address - Phone:816-743-0085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006017162225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant