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General NPI Number Information
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NPI Number | 1255700555
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Entity Type | Organization
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Legal Business Name | ACTION JACKSON PHYSICAL THERAPY, P.C.
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Dates
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Enumeration Date | 09/17/2015
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Last Update Date | 09/17/2015
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Provider Practice Location Address
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Address Line | 2844 SUMMIT ST SUITE 106
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City | OAKLAND
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State | CA
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Zip | 94609-3637
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Country | US
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Telephone | 510-763-3005
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Fax |
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Provider Business Mailing Address
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Address Line | 1005 SOLANO AVE APT. A
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City | ALBANY
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State | CA
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Zip | 94706-1617
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Country | US
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Telephone | 510-292-5385
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | MR. SHANE LORAN JACKSON
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Credential | DPT
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Telephone | 510-292-5385
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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 | PT23897
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License Number State | CA
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