Provider Demographics
NPI:1952730491
Name:JACKSON, ERICK LARON (DPT)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:LARON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 MDG/OPERATIONAL SUPPORT TEAM
Mailing Address - Street 2:7219 N. LITCHFIELD RD
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85309
Mailing Address - Country:US
Mailing Address - Phone:623-856-4985
Mailing Address - Fax:
Practice Address - Street 1:325 MDG/PHYSICAL THERAPY
Practice Address - Street 2:340 MAGNOLIA CIRCLE
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403
Practice Address - Country:US
Practice Address - Phone:850-283-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist