Provider Demographics
NPI:1063440436
Name:JACKSON, CHANDA D'RIECE (PT)
Entity type:Individual
Prefix:
First Name:CHANDA
Middle Name:D'RIECE
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:PO BOX 797
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:OK
Mailing Address - Zip Code:73669-0797
Mailing Address - Country:US
Mailing Address - Phone:580-661-2639
Mailing Address - Fax:580-661-2640
Practice Address - Street 1:100 S 2ND STREET
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:OK
Practice Address - Zip Code:73669
Practice Address - Country:US
Practice Address - Phone:580-661-2639
Practice Address - Fax:580-661-2640
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK242721402Medicare PIN