Provider Demographics
NPI:1891803946
Name:JACKSON, WILLIAM R JR (PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3563
Mailing Address - Country:US
Mailing Address - Phone:334-613-9000
Mailing Address - Fax:334-532-0056
Practice Address - Street 1:454 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3563
Practice Address - Country:US
Practice Address - Phone:334-613-9000
Practice Address - Fax:334-532-0056
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-65213OtherBCBS OF AL
AL12735291OtherCAQH
AL511-65211OtherBCBS OF AL
AL511-65212OtherBCBS OF AL
AL102I652298Medicare PIN
AL12735291OtherCAQH
AL102I652300Medicare PIN