Healthcare Provider Details

I. General information

NPI: 1982567590
Provider Name (Legal Business Name): JACKSON THOMAS ROYSTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19460 OLD JETTON RD STE 202
CORNELIUS NC
28031-6763
US

IV. Provider business mailing address

19460 OLD JETTON RD STE 202
CORNELIUS NC
28031-6763
US

V. Phone/Fax

Practice location:
  • Phone: 704-255-6879
  • Fax: 704-255-6881
Mailing address:
  • Phone: 704-255-6879
  • Fax: 704-255-6881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP24537
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: