Provider Demographics
NPI:1669528857
Name:JACKSON REHAB SERVICES, LLC
Entity type:Organization
Organization Name:JACKSON REHAB SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:806-778-9735
Mailing Address - Street 1:5728 67TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1406
Mailing Address - Country:US
Mailing Address - Phone:806-778-9735
Mailing Address - Fax:
Practice Address - Street 1:5728 67TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1406
Practice Address - Country:US
Practice Address - Phone:806-778-9735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102473225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0077JNOtherBLUE CROSS - OT
TX00963UMedicare ID - Type UnspecifiedOCCUPATIONAL THERAPY