Healthcare Provider Details

I. General information

NPI: 1003511908
Provider Name (Legal Business Name): DR. KATIE JACKSON'S WOUND, OSTOMY AND FOOTCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/03/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 GLENWOOD RD
RUTLAND MA
01543-1614
US

IV. Provider business mailing address

16 WOODLAND DR
WESTMINSTER MA
01473-1132
US

V. Phone/Fax

Practice location:
  • Phone: 978-821-0842
  • Fax:
Mailing address:
  • Phone: 978-821-0842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATIE JACKSON
Title or Position: PT, OWNER
Credential: PT
Phone: 978-821-0842