MEDICARE: VALERIE B 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	15142	CA

General Provider Information

NPI Number	:	1508922279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VALERIE B JACKSON PT

Provider Business Mailing Address
First Line	:	525 SOUTH DR STE 211
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-4211
Country	:	US
Telephone Number	:	650-934-0455
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 SOUTH DR STE 211
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-4211
Country	:	US
Telephone Number	:	650-934-0455
Fax Number	:	650-934-0456

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	03/04/2008

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