Provider Demographics
NPI:1669866786
Name:JACKSON, EMMA (DPT)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:MITCHELL-REKRUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1 CREDIT UNION WAY
Mailing Address - Street 2:FL. 3
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 406
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:781-646-8440
Practice Address - Fax:781-643-7542
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400274054OtherMEDICARE PTAN
MA110110967AMedicaid