Provider Demographics
NPI:1992161921
Name:JACKSON, CLAIRE EMMA
Entity type:Individual
Prefix:
First Name:CLAIRE
Middle Name:EMMA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 RIVERS BEND BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-8632
Mailing Address - Country:US
Mailing Address - Phone:804-526-5888
Mailing Address - Fax:804-526-5401
Practice Address - Street 1:325 CHARLES H DIMMOCK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2986
Practice Address - Country:US
Practice Address - Phone:804-526-5888
Practice Address - Fax:804-526-5401
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209896225100000X
OHPT015445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist