Provider Demographics
NPI:1295062792
Name:JACKSON, JONATHAN MARK (DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARK
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 1:1000 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3430
Mailing Address - Country:US
Mailing Address - Phone:503-842-4444
Mailing Address - Fax:
Practice Address - Street 1:1000 3RD ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3430
Practice Address - Country:US
Practice Address - Phone:503-842-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35976225100000X
IDPT-2974225100000X
OR60682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist