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NPI Code Detail

MEDICARE: CHEVIS M JACKSON

MEDICARE: CHEVIS M JACKSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy AssistantPTA003382GA

General Provider Information

NPI Number : 1205413507
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHEVIS M JACKSON
Provider Business Mailing Address
First Line : 1335 OAKSHYRE PL
Second Line :
City : LAWRENCEVILLE
State : GA
Zip : 30043-6435
Country : US
Telephone Number : 504-912-5169
Fax Number :
Provider Business Practice Location Address
First Line : 125 SAMARITAN DR
Second Line :
City : CUMMING
State : GA
Zip : 30040-2354
Country : US
Telephone Number : 770-889-1644
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2021
Last Update Date : 03/24/2021

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