Provider Demographics
NPI:1780341032
Name:MCQUEEN, JACKSON WADE (ATC)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:WADE
Last Name:MCQUEEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 PENROSE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-8638
Mailing Address - Country:US
Mailing Address - Phone:325-977-1914
Mailing Address - Fax:
Practice Address - Street 1:3300 W CAMELBACK RD # A21367
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3030
Practice Address - Country:US
Practice Address - Phone:325-977-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program