Provider Demographics
NPI:1669945465
Name:JACKSON, HANNAH JACQUELINE (PTA)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:JACQUELINE
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 1:804 PETRA PASS
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-8772
Mailing Address - Country:US
Mailing Address - Phone:540-808-9132
Mailing Address - Fax:
Practice Address - Street 1:KROONTJE HEALTHCARE CENTER
Practice Address - Street 2:100 LITTON LANE
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060
Practice Address - Country:US
Practice Address - Phone:540-443-3437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604661225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant