Provider Demographics
NPI:1972009041
Name:JACKSON, CHRISTOPHER CARL (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:CARL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12739 HIGHWAY 171 STE B
Mailing Address - Street 2:
Mailing Address - City:LONGVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70652-5050
Mailing Address - Country:US
Mailing Address - Phone:337-317-9290
Mailing Address - Fax:337-725-4457
Practice Address - Street 1:12739 HIGHWAY 171 STE B
Practice Address - Street 2:
Practice Address - City:LONGVILLE
Practice Address - State:LA
Practice Address - Zip Code:70652-5050
Practice Address - Country:US
Practice Address - Phone:337-317-9290
Practice Address - Fax:337-725-4457
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty