Provider Demographics
NPI:1891171468
Name:JACKOWSKI, MICHAEL J
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:JACKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6499 E BROAD ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-6505
Mailing Address - Country:US
Mailing Address - Phone:614-355-9760
Mailing Address - Fax:
Practice Address - Street 1:6499 E BROAD ST
Practice Address - Street 2:SUITE 140
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-6505
Practice Address - Country:US
Practice Address - Phone:614-355-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH114812251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic