Healthcare Provider Details

I. General information

NPI: 1700509247
Provider Name (Legal Business Name): CAMERON JACKSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 AMES ST
BALDWIN CITY KS
66006-5200
US

IV. Provider business mailing address

603 AMES ST
BALDWIN CITY KS
66006-5200
US

V. Phone/Fax

Practice location:
  • Phone: 785-594-4894
  • Fax: 785-594-2597
Mailing address:
  • Phone: 785-594-4894
  • Fax: 786-594-2597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11-06988
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: