MEDICARE: JOANNA JACKSON

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	051568-01	NY

General Provider Information

NPI Number	:	1659063956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNA JACKSON

Provider Business Mailing Address
First Line	:	800 HERTEL AVE # 101
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14207-1906
Country	:	US
Telephone Number	:	716-566-5050
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 HERTEL AVE STE 101
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14207-1906
Country	:	US
Telephone Number	:	716-566-5050
Fax Number	:

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

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	03/17/2026

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