Provider Demographics
NPI:1962624387
Name:JACKSON, JUDY EVA (PT)
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:EVA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38435 5TH ST W
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4423
Mailing Address - Country:US
Mailing Address - Phone:310-404-1558
Mailing Address - Fax:
Practice Address - Street 1:38435 5TH ST. W
Practice Address - Street 2:APT J155
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551
Practice Address - Country:US
Practice Address - Phone:310-404-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist