MEDICARE: MR. STEPHEN JACKSON PT, DPT

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
1	225100000X	Physical Therapist	09089	LA

General Provider Information

NPI Number	:	1275918401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN JACKSON PT, DPT

Provider Business Mailing Address
First Line	:	13053 HWY. 73
Second Line	:	STE. B
City	:	GEISMAR
State	:	LA
Zip	:	70734-3021
Country	:	US
Telephone Number	:	225-744-3631
Fax Number	:	225-744-3647

Provider Business Practice Location Address
First Line	:	13053 HWY. 73
Second Line	:	STE. B
City	:	GEISMAR
State	:	LA
Zip	:	70734-3021
Country	:	US
Telephone Number	:	225-744-3631
Fax Number	:	225-744-3647

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2015
Last Update Date	:	01/20/2026

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