Provider Demographics
NPI:1982812244
Name:JACKSON, JAMIE A (MPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-3612
Mailing Address - Country:US
Mailing Address - Phone:301-254-1545
Mailing Address - Fax:
Practice Address - Street 1:2301 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-4504
Practice Address - Country:US
Practice Address - Phone:215-228-2656
Practice Address - Fax:215-228-2661
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA018657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist