MEDICARE: MISS BONNIE JEAN JACKSON PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	11679	MA

General Provider Information

NPI Number	:	1033127592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS BONNIE JEAN JACKSON PT

Provider Business Mailing Address
First Line	:	16 POPLAR LN
Second Line	:
City	:	BREWSTER
State	:	MA
Zip	:	02631-2138
Country	:	US
Telephone Number	:	508-240-0024
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 WHITES PATH
Second Line	:	SUITE O2
City	:	SOUTH YARMOUTH
State	:	MA
Zip	:	02664-1221
Country	:	US
Telephone Number	:	508-240-0024
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/08/2007

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