Provider Demographics
NPI:1942651708
Name:JACKSON, GREGORY (PTA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9685 CHILLICOTHE RD
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-8503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9685 CHILLICOTHE RD
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-8503
Practice Address - Country:US
Practice Address - Phone:440-256-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08890225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant