Provider Demographics
NPI:1538164827
Name:JACKSON, CAROL JEAN (PT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 N 1ST ST STE 103
Mailing Address - Street 2:STEP AHEAD PHYSICAL THERAPY
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1845
Mailing Address - Country:US
Mailing Address - Phone:818-846-7100
Mailing Address - Fax:818-846-7101
Practice Address - Street 1:100 N 1ST ST STE 103
Practice Address - Street 2:STEP AHEAD PHYSICAL THERAPY
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1845
Practice Address - Country:US
Practice Address - Phone:818-846-7100
Practice Address - Fax:818-846-7101
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20-0700404OtherTAX I.D. # FOR FACILITY
CAOPT176510OtherBLUE SHIELD
CAOPT176510OtherBLUE SHIELD