Provider Demographics
NPI:1700509247
Name:JACKSON, CAMERON (DPT)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:JACKSON
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:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:KS
Mailing Address - Zip Code:67878-0542
Mailing Address - Country:US
Mailing Address - Phone:620-282-3636
Mailing Address - Fax:
Practice Address - Street 1:700 N HUSER ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:KS
Practice Address - Zip Code:67878-7700
Practice Address - Country:US
Practice Address - Phone:620-384-7462
Practice Address - Fax:620-384-6679
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist