Healthcare Provider Details

I. General information

NPI: 1649196379
Provider Name (Legal Business Name): JORDAN JACKSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3135 LONG BEACH RD
OCEANSIDE NY
11572
US

IV. Provider business mailing address

3135 LONG BEACH RD
OCEANSIDE NY
11572
US

V. Phone/Fax

Practice location:
  • Phone: 516-207-0933
  • Fax: 516-613-2548
Mailing address:
  • Phone: 516-207-0933
  • Fax: 516-613-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: