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General NPI Number Information
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NPI Number | 1467072041
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Entity Type | Individual
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Provider Name | CHASITY JACKSON DPT
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Gender | Female
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Dates
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Enumeration Date | 04/23/2020
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Last Update Date | 11/01/2022
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Provider Practice Location Address
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Address Line | 1535 RIVER PARKWAY BLVD APT 208
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City | SHREVEPORT
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State | LA
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Zip | 71104-1803
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Country | US
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Telephone | 870-665-9462
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Fax |
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Provider Business Mailing Address
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Address Line | 245 PEREGRINE WAY
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City | BOSSIER CITY
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State | LA
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Zip | 71112-2556
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Country | US
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Telephone | 870-665-9462
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Fax |
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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 | 09698R
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License Number State | LA
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