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NPI Code Detail

MEDICARE: ERIN HOSIE JACKSON MSPT, CPI

MEDICARE: ERIN HOSIE JACKSON MSPT, CPI
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
1225100000XPhysical Therapist20223CA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1DQ684AOTHERCAMEDICARE PTAN

General Provider Information

NPI Number : 1366555211
Entity Type Code : Individual
Provider Name (Legal Business Name) : ERIN HOSIE JACKSON MSPT, CPI
Provider Business Mailing Address
First Line : 11 BANEBERRY
Second Line :
City : ALISO VIEJO
State : CA
Zip : 92656-2147
Country : US
Telephone Number : 949-716-9616
Fax Number : 949-494-3222
Provider Business Practice Location Address
First Line : 1100 S COAST HWY
Second Line : SUITE 301 B
City : LAGUNA BEACH
State : CA
Zip : 92651-2968
Country : US
Telephone Number : 949-494-3200
Fax Number : 949-494-3222
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/16/2006
Last Update Date : 12/22/2010

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