Provider Demographics
NPI:1861719726
Name:JACKSON, MEGHAN E (DPT)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:E
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, OMPT
Mailing Address - Street 1:29255 NORTHWESTERN HWY.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5742
Mailing Address - Country:US
Mailing Address - Phone:248-353-1234
Mailing Address - Fax:248-353-1211
Practice Address - Street 1:29255 NORTHWESTERN HWY.
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5742
Practice Address - Country:US
Practice Address - Phone:248-353-1234
Practice Address - Fax:248-353-1211
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist