Provider Demographics
NPI:1205320405
Name:JACKSON, ZACHARY BRADLEY (DPT)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:BRADLEY
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 1:2205 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3113
Mailing Address - Country:US
Mailing Address - Phone:575-652-3515
Mailing Address - Fax:575-652-3518
Practice Address - Street 1:2205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3113
Practice Address - Country:US
Practice Address - Phone:575-652-3515
Practice Address - Fax:575-652-3518
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212070225100000X
NMPT5353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist