Healthcare Provider Details

I. General information

NPI: 1104088749
Provider Name (Legal Business Name): KATHY JACKSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 W GROVE ST
EL DORADO AR
71730-4416
US

IV. Provider business mailing address

3308 DOGWOOD RD
EL DORADO AR
71730-4155
US

V. Phone/Fax

Practice location:
  • Phone: 870-881-4677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT278
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: