Provider Demographics
NPI:1992027775
Name:JACKSON, MATTHEW (DPT, MOT,ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT, MOT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 NINTH ST
Mailing Address - Street 2:
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342
Mailing Address - Country:US
Mailing Address - Phone:318-992-9200
Mailing Address - Fax:318-992-9280
Practice Address - Street 1:187 NINTH ST
Practice Address - Street 2:
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342-2780
Practice Address - Country:US
Practice Address - Phone:318-992-9200
Practice Address - Fax:318-992-9280
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07464225100000X, 2255A2300X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07464OtherLA STATE LICENSE