Healthcare Provider Details

I. General information

NPI: 1336594696
Provider Name (Legal Business Name): TYLER JACKSON MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MONTGOMERY AVE
BRYN MAWR PA
19010-1631
US

IV. Provider business mailing address

325 PONDVIEW DR
HARLEYSVILLE PA
19438-2395
US

V. Phone/Fax

Practice location:
  • Phone: 610-527-0200
  • Fax:
Mailing address:
  • Phone: 267-885-5377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT006884
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: