MEDICARE: MR. HENRY JACKSON P.T.

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	003461	NY

General Provider Information

NPI Number	:	1063667053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY JACKSON P.T.

Provider Business Mailing Address
First Line	:	5605 TILDEN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-4819
Country	:	US
Telephone Number	:	718-451-2905
Fax Number	:	718-451-2577

Provider Business Practice Location Address
First Line	:	5605 TILDEN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-4819
Country	:	US
Telephone Number	:	718-451-2905
Fax Number	:	718-451-2577

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

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	11/18/2008

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