Provider Demographics
NPI:1922367705
Name:JACKSON, RITA (PT)
Entity Type:Individual
Prefix:
First Name:RITA
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:PO BOX 130004
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77393-0004
Mailing Address - Country:US
Mailing Address - Phone:713-805-1561
Mailing Address - Fax:
Practice Address - Street 1:23 SKY TERRACE PL
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77381-3186
Practice Address - Country:US
Practice Address - Phone:713-805-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1027068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist