Provider Demographics
NPI:1730221029
Name:JACKSON, GERALD MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:MICHAEL
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 1:2100 E CALVADA BLVD
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-5805
Mailing Address - Country:US
Mailing Address - Phone:775-727-7959
Mailing Address - Fax:775-727-7960
Practice Address - Street 1:2100 E CALVADA BLVD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5805
Practice Address - Country:US
Practice Address - Phone:775-727-7959
Practice Address - Fax:775-727-7960
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1730221029Medicaid
NVV37988Medicare ID - Type UnspecifiedPHC INC