MEDICARE: CHASITY RENEA JACKSON-ELLIS 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	07075	LA

General Provider Information

NPI Number	:	1396479069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHASITY RENEA JACKSON-ELLIS DPT

Provider Business Mailing Address
First Line	:	377 LEIGH LN
Second Line	:
City	:	STONEWALL
State	:	LA
Zip	:	71078-5414
Country	:	US
Telephone Number	:	318-458-9464
Fax Number	:

Provider Business Practice Location Address
First Line	:	423 TREELINE PARK STE 201
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-2078
Country	:	US
Telephone Number	:	210-602-0235
Fax Number	:

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

Provider Enumeration Date	:	07/10/2022
Last Update Date	:	07/10/2022

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