MEDICARE: SUZANNE SAMMONS JACKSON PT

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	2251X0800X	Orthopedic Physical Therapist	PT6206	FL

General Provider Information

NPI Number	:	1346451739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE SAMMONS JACKSON PT

Provider Business Mailing Address
First Line	:	2579 JARDIN DRIVE
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33327
Country	:	US
Telephone Number	:	954-594-0299
Fax Number	:

Provider Business Practice Location Address
First Line	:	5856 S FLAMINGO RD
Second Line	:
City	:	COOPER CITY
State	:	FL
Zip	:	33330-3238
Country	:	US
Telephone Number	:	954-252-6014
Fax Number	:	954-252-6015

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

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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