Provider Demographics
NPI:1306513841
Name:CAVANAUGH, JACKSON TOBIN (DPT)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:TOBIN
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 COURT DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2180
Mailing Address - Country:US
Mailing Address - Phone:704-864-5550
Mailing Address - Fax:704-864-5550
Practice Address - Street 1:2555 COURT DR STE 400
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2180
Practice Address - Country:US
Practice Address - Phone:704-864-5550
Practice Address - Fax:704-864-5550
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014254A225100000X
NCCP022613T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist