Provider Demographics
NPI:1982162905
Name:JACKSON, JACOB S (DPT)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:S
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 1:4110 S WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6544
Mailing Address - Country:US
Mailing Address - Phone:618-242-1100
Mailing Address - Fax:618-244-5148
Practice Address - Street 1:4110 S WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6544
Practice Address - Country:US
Practice Address - Phone:618-242-1100
Practice Address - Fax:618-244-5148
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist