Provider Demographics
NPI:1336223411
Name:JACKSON, BOBBI JEAN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BOBBI
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 HOPPER BARKER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9462
Mailing Address - Country:US
Mailing Address - Phone:731-668-9989
Mailing Address - Fax:
Practice Address - Street 1:2031 AVONDALE ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-1810
Practice Address - Country:US
Practice Address - Phone:731-784-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant