Provider Demographics
NPI:1952338337
Name:JACKSON, KEITH (MPT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1812 MARSH RD
Practice Address - Street 2:STORE 505
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4581
Practice Address - Country:US
Practice Address - Phone:302-475-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21348225100000X
DEJ1-0001883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
50700032OtherCAREFIRST
5070-0032OtherNCA
64343601OtherCARE FIRST
246555OtherMAMSI
64343601OtherCAREFIRST
1530795OtherPABS
2342330000OtherAMERIHEALTH
2342330000OtherAMERIHEALTH
64343601OtherCAREFIRST
P00635525Medicare PIN
5070-0032OtherNCA