=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396479069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHASITY RENEA JACKSON-ELLIS DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2022
-----------------------------------------------------
Last Update Date | 07/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 423 TREELINE PARK STE 201
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78209-2078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-602-0235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 377 LEIGH LN
-----------------------------------------------------
City | STONEWALL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71078-5414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-458-9464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 07075
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------