Provider Demographics
NPI:1013423391
Name:JACKSON, HERMAN L (PTA)
Entity Type:Individual
Prefix:MR
First Name:HERMAN
Middle Name:L
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 1:24 E 109TH ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3472
Mailing Address - Country:US
Mailing Address - Phone:347-680-2272
Mailing Address - Fax:
Practice Address - Street 1:PHYSICAL THERAPY OF HARLEM 1400 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10026
Practice Address - Country:US
Practice Address - Phone:212-996-3303
Practice Address - Fax:212-996-9686
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008098225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant