MEDICARE: DAVID ANDREW JACKSON P.T.

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	05002999	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000042777	OTHER	IN	ANTHEM PIN #
2	64-00191	OTHER	IN	UHC PIN #

General Provider Information

NPI Number	:	1679547269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID ANDREW JACKSON P.T.

Provider Business Mailing Address
First Line	:	326 N INDIANA AVE
Second Line	:
City	:	SELLERSBURG
State	:	IN
Zip	:	47172-1223
Country	:	US
Telephone Number	:	812-246-8975
Fax Number	:	812-246-8977

Provider Business Practice Location Address
First Line	:	326 N INDIANA AVE
Second Line	:
City	:	SELLERSBURG
State	:	IN
Zip	:	47172-1223
Country	:	US
Telephone Number	:	812-246-8975
Fax Number	:	812-246-8977

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

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	07/09/2007

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