Provider Demographics
NPI:1750513925
Name:JACKSON-LEWIS, NIA MALIKA (PT)
Entity type:Individual
Prefix:MRS
First Name:NIA
Middle Name:MALIKA
Last Name:JACKSON-LEWIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 MURRAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76567-2763
Mailing Address - Country:US
Mailing Address - Phone:512-446-9990
Mailing Address - Fax:512-446-9991
Practice Address - Street 1:701 MURRAY AVE
Practice Address - Street 2:
Practice Address - City:ROCKDALE
Practice Address - State:TX
Practice Address - Zip Code:76567-2763
Practice Address - Country:US
Practice Address - Phone:512-446-9990
Practice Address - Fax:512-446-9991
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1157560225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist