Provider Demographics
NPI:1306134267
Name:JACKSON, DAILE M (PT, DPT)
Entity type:Individual
Prefix:
First Name:DAILE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:DAILE
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3266 FLUVANNA AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:FLUVANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9706
Mailing Address - Country:US
Mailing Address - Phone:716-665-0773
Mailing Address - Fax:
Practice Address - Street 1:774 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2609
Practice Address - Country:US
Practice Address - Phone:716-665-1166
Practice Address - Fax:866-902-1160
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033817-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03424691Medicaid
NYJ400055411Medicare Oscar/Certification