Healthcare Provider Details

I. General information

NPI: 1588429161
Provider Name (Legal Business Name): LEO JACKSON III PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WHITE ST SW STE 300
ATLANTA GA
30310-2634
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 470-905-2800
  • Fax: 470-905-2801
Mailing address:
  • Phone: 586-350-2644
  • Fax: 586-541-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017004
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: