Provider Demographics
NPI:1891210456
Name:JACKSON, ETHAN GAINOR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:GAINOR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:455 PHILIP BLVD BLDG 100-160
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8767
Practice Address - Country:US
Practice Address - Phone:678-985-0238
Practice Address - Fax:678-985-0136
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist