Provider Demographics
NPI:1124421631
Name:JACKSON THERAPY
Entity type:Organization
Organization Name:JACKSON THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:610-737-2524
Mailing Address - Street 1:849 S GUN BARREL LN # LM
Mailing Address - Street 2:UNIT G5
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-9335
Mailing Address - Country:US
Mailing Address - Phone:610-737-2524
Mailing Address - Fax:
Practice Address - Street 1:849 S GUN BARREL LN # LM
Practice Address - Street 2:UNIT G5
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-9335
Practice Address - Country:US
Practice Address - Phone:610-737-2524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1249341252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency