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General NPI Number Information
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NPI Number | 1124421631
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Entity Type | Organization
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Legal Business Name | JACKSON THERAPY
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Dates
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Enumeration Date | 09/29/2014
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Last Update Date | 09/29/2014
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Provider Practice Location Address
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Address Line | 849 S GUN BARREL LN # LM UNIT G5
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City | GUN BARREL CITY
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State | TX
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Zip | 75156-9335
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Country | US
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Telephone | 610-737-2524
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Fax |
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Provider Business Mailing Address
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Address Line | 849 S GUN BARREL LN # LM UNIT G5
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City | GUN BARREL CITY
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State | TX
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Zip | 75156-9335
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Country | US
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Telephone | 610-737-2524
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | SAMANTHA MOYER
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Credential | DPT
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Telephone | 610-737-2524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 1249341
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License Number State | TX
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