Provider Demographics
NPI:1548456502
Name:JACKSON, DAVID NATHAN (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:NATHAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6336
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6336
Mailing Address - Country:US
Mailing Address - Phone:903-388-8378
Mailing Address - Fax:
Practice Address - Street 1:7922 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5242
Practice Address - Country:US
Practice Address - Phone:903-983-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-23
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1156269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist