Provider Demographics
NPI:1992453310
Name:JACKSON, BRITTANY ANN (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 E WASHINGTON AVE APT 507
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-4413
Mailing Address - Country:US
Mailing Address - Phone:845-978-3314
Mailing Address - Fax:
Practice Address - Street 1:800 MEDCALF ST
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-1300
Practice Address - Country:US
Practice Address - Phone:360-249-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15753-24225100000X
WACP014479T225100000X
AZLPT-30358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist