Provider Demographics
NPI:1588261879
Name:MIAO, JACKSON (DPT)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:MIAO
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 1:1824 VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2922
Mailing Address - Country:US
Mailing Address - Phone:415-335-2039
Mailing Address - Fax:
Practice Address - Street 1:1040 N RENGSTORFF AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-1750
Practice Address - Country:US
Practice Address - Phone:650-967-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT298428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist