Healthcare Provider Details

I. General information

NPI: 1023990561
Provider Name (Legal Business Name): ELIZABETH JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1446 HARPER ST
AUGUSTA GA
30912-0012
US

IV. Provider business mailing address

4304 CANDLEBERRY GDN
NORTH AUGUSTA SC
29860-7203
US

V. Phone/Fax

Practice location:
  • Phone: 762-375-2396
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH JACKSON
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 912-585-4211