Provider Demographics
NPI:1023527041
Name:JACKSON, DAVID BLAKE (DPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BLAKE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 SHOPPERS DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-2806
Mailing Address - Country:US
Mailing Address - Phone:859-745-7995
Mailing Address - Fax:859-745-0115
Practice Address - Street 1:273 SHOPPERS DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-2806
Practice Address - Country:US
Practice Address - Phone:859-745-7995
Practice Address - Fax:859-745-0115
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100489410Medicaid