Provider Demographics
NPI:1194543223
Name:JACKSON, KENLEY BROOKE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENLEY
Middle Name:BROOKE
Last Name:JACKSON
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10618 BRECKENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1802
Mailing Address - Country:US
Mailing Address - Phone:501-217-8600
Mailing Address - Fax:501-217-8636
Practice Address - Street 1:1500 N MISSISSIPPI ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-5851
Practice Address - Country:US
Practice Address - Phone:501-217-8600
Practice Address - Fax:501-217-8636
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT5545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist