Provider Demographics
NPI:1700509247
Name:JACKSON, CAMERON (DPT)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
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 1:603 AMES ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66006-5200
Mailing Address - Country:US
Mailing Address - Phone:785-594-4894
Mailing Address - Fax:786-594-2597
Practice Address - Street 1:603 AMES ST
Practice Address - Street 2:
Practice Address - City:BALDWIN CITY
Practice Address - State:KS
Practice Address - Zip Code:66006-5200
Practice Address - Country:US
Practice Address - Phone:785-594-4894
Practice Address - Fax:785-594-2597
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist