Provider Demographics
NPI:1427795798
Name:JACKSON, DAVID ARTHUR (DPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ARTHUR
Last Name:JACKSON
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 1:3810 LA CRESCENTA AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3914
Mailing Address - Country:US
Mailing Address - Phone:818-369-7700
Mailing Address - Fax:818-369-7702
Practice Address - Street 1:3810 LA CRESCENTA AVE
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3914
Practice Address - Country:US
Practice Address - Phone:818-369-7700
Practice Address - Fax:818-369-7702
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist