Provider Demographics
NPI:1700579968
Name:JACKSON, JORDAN ALEXA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ALEXA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9307 W 146TH PL
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-2258
Mailing Address - Country:US
Mailing Address - Phone:913-909-4690
Mailing Address - Fax:
Practice Address - Street 1:1445 S MAHAFFIE ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-3464
Practice Address - Country:US
Practice Address - Phone:913-232-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-072962251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty