Provider Demographics
NPI:1669148391
Name:JACKS, CODY JEFFERSON (DPT)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:JEFFERSON
Last Name:JACKS
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 1:5874 AVERY WAY
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-3095
Mailing Address - Country:US
Mailing Address - Phone:907-602-2617
Mailing Address - Fax:
Practice Address - Street 1:2835 CHILDRESS DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3563
Practice Address - Country:US
Practice Address - Phone:530-378-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist