Provider Demographics
NPI:1831929298
Name:JACKSON, AMBER RAE (DPT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:RAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 S BARRETT RD
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-5312
Mailing Address - Country:US
Mailing Address - Phone:530-635-3886
Mailing Address - Fax:
Practice Address - Street 1:420 B ST
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-5070
Practice Address - Country:US
Practice Address - Phone:530-674-8850
Practice Address - Fax:530-674-8855
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist