Healthcare Provider Details

I. General information

NPI: 1700762739
Provider Name (Legal Business Name): MACKENZIE D JACKSON-RUTH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 RIVERSIDE AVE
JACKSONVILLE FL
32202-4912
US

IV. Provider business mailing address

PO BOX 932184
ATLANTA GA
31193-2184
US

V. Phone/Fax

Practice location:
  • Phone: 904-579-2824
  • Fax:
Mailing address:
  • Phone: 856-678-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT43435
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: