Provider Demographics
NPI:1396479069
Name:JACKSON-ELLIS, CHASITY RENEA (DPT)
Entity type:Individual
Prefix:
First Name:CHASITY
Middle Name:RENEA
Last Name:JACKSON-ELLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 LEIGH LN
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-5414
Mailing Address - Country:US
Mailing Address - Phone:318-458-9464
Mailing Address - Fax:
Practice Address - Street 1:423 TREELINE PARK STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2078
Practice Address - Country:US
Practice Address - Phone:210-602-0235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-10
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist