Healthcare Provider Details

I. General information

NPI: 1336223411
Provider Name (Legal Business Name): BOBBI JEAN JACKSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 AVONDALE ST
HUMBOLDT TN
38343-1810
US

IV. Provider business mailing address

268 HOPPER BARKER RD
JACKSON TN
38305-9462
US

V. Phone/Fax

Practice location:
  • Phone: 731-784-3655
  • Fax:
Mailing address:
  • Phone: 731-668-9989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3108
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: