Provider Demographics
NPI:1629113600
Name:JACKSON, AMY (PT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 STONYBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-8905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1609 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1806
Practice Address - Country:US
Practice Address - Phone:419-671-0001
Practice Address - Fax:419-539-0288
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-10851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000362244OtherANTHEM PROVIDER NUMBER