Provider Demographics
NPI:1770357105
Name:JACKSON, TAYLOR NICOLE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-1015
Mailing Address - Country:US
Mailing Address - Phone:860-684-6528
Mailing Address - Fax:860-684-5263
Practice Address - Street 1:77 W STAFFORD RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-1015
Practice Address - Country:US
Practice Address - Phone:860-684-6528
Practice Address - Fax:860-684-5263
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist