Healthcare Provider Details

I. General information

NPI: 1538406095
Provider Name (Legal Business Name): JESSICA ROBIN JACKSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DELAWARE AVE
DELMAR DE
19940-1110
US

IV. Provider business mailing address

101 DELAWARE AVE
DELMAR DE
19940-1110
US

V. Phone/Fax

Practice location:
  • Phone: 302-846-3077
  • Fax: 302-846-3462
Mailing address:
  • Phone: 302-846-3077
  • Fax: 302-846-3462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberJ2-0000704
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: