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NPI Code Detail

MEDICARE: DONICA CHIVON JACKSON CPTA

MEDICARE: DONICA CHIVON JACKSON CPTA
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
1225200000XPhysical Therapy Assistant2006017162MO

General Provider Information

NPI Number : 1881039683
Entity Type Code : Individual
Provider Name (Legal Business Name) : DONICA CHIVON JACKSON CPTA
Provider Business Mailing Address
First Line : 1624 WOODLAND BLVD
Second Line :
City : KANSAS CITY
State : KS
Zip : 66106-2842
Country : US
Telephone Number : 913-406-3044
Fax Number :
Provider Business Practice Location Address
First Line : 11900 JESSICA LN
Second Line :
City : RAYTOWN
State : MO
Zip : 64138-2649
Country : US
Telephone Number : 816-743-0085
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/07/2013
Last Update Date : 05/07/2013

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