MEDICARE: GEORONIKA 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	225100000X	Physical Therapist	1289681	TX

General Provider Information

NPI Number	:	1871022061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORONIKA JACKSON PT

Provider Business Mailing Address
First Line	:	26400 KUYKENDAHL RD
Second Line	:	SUITE C-180, #113
City	:	THE WOODLANDS
State	:	TX
Zip	:	77375-2946
Country	:	US
Telephone Number	:	281-734-2408
Fax Number	:

Provider Business Practice Location Address
First Line	:	4806 RIVERSTONE BLVD
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4092
Country	:	US
Telephone Number	:	281-499-5808
Fax Number	:	281-499-5808

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

Provider Enumeration Date	:	06/09/2017
Last Update Date	:	06/09/2017

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