Healthcare Provider Details

I. General information

NPI: 1801036306
Provider Name (Legal Business Name): JANE M JACKSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16838 E PALISADES BLVD BLDG B
FOUNTAIN HILLS AZ
85268-3845
US

IV. Provider business mailing address

9097 E DESERT COVE AVE SUITE110
SCOTTSDALE AZ
85260-6710
US

V. Phone/Fax

Practice location:
  • Phone: 480-837-2595
  • Fax: 480-837-2773
Mailing address:
  • Phone: 480-860-4298
  • Fax: 480-860-0356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6716A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: