Provider Demographics
NPI:1740902063
Name:PRICE, JACKSON (DPT)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:PRICE
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 1:1323 VALLE LN
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 OLD GREENWOOD RD STE 14
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4560
Practice Address - Country:US
Practice Address - Phone:479-222-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist