Healthcare Provider Details

I. General information

NPI: 1639520380
Provider Name (Legal Business Name): HEATHER DANIELLE JACKSON PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER DANIELLE DRAGG PT, DPT

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 BOLIVAR ST STE 100
SANGER TX
76266-9775
US

IV. Provider business mailing address

3301 SUNDOWN BLVD
DENTON TX
76210-8032
US

V. Phone/Fax

Practice location:
  • Phone: 940-387-7601
  • Fax: 940-257-6200
Mailing address:
  • Phone: 940-387-3700
  • Fax: 940-488-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5193
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1324782
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: