Provider Demographics
NPI:1588076970
Name:JACKSON, BRETT RANDALL (DPT, ATC)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:RANDALL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 CALIFORNIA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-5260
Mailing Address - Country:US
Mailing Address - Phone:800-456-5857
Mailing Address - Fax:
Practice Address - Street 1:13609 CALIFORNIA ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5260
Practice Address - Country:US
Practice Address - Phone:800-456-5857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT871604225100000X
MI5501016594225100000X
FLPT27854225100000X
MA157902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist