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General NPI Number Information
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NPI Number | 1235306143
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Entity Type | Individual
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Provider Name | JOSEPH JACKSON R.P.T.
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Gender | Male
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Dates
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Enumeration Date | 05/09/2008
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Last Update Date | 05/09/2008
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Provider Practice Location Address
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Address Line | 15640 S NORMANDIE AVE
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City | GARDENA
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State | CA
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Zip | 90247-4016
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Country | US
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Telephone | 310-631-8703
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Fax | 310-763-0400
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Provider Business Mailing Address
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Address Line | 1954 ATLANTIC AVE
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City | LONG BEACH
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State | CA
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Zip | 90806-5510
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Country | US
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Telephone | 310-631-8703
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Fax | 562-591-1422
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT5788
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License Number State | CA
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