Provider Demographics
NPI:1669740130
Name:JACKSON, MARY COBBS (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:COBBS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 DUMAINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-218-1993
Mailing Address - Fax:
Practice Address - Street 1:1700 BUCKNER ST STE 150
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4407
Practice Address - Country:US
Practice Address - Phone:318-218-1993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist