Provider Demographics
NPI:1942603568
Name:JACKSON, JILL MARIE (DPT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:POLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2882 HOLLY HALL ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-4160
Mailing Address - Country:US
Mailing Address - Phone:208-313-6065
Mailing Address - Fax:
Practice Address - Street 1:3601 N MACGREGOR WAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-8004
Practice Address - Country:US
Practice Address - Phone:713-873-4637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-28
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2679225100000X
TX1242179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist