MEDICARE: JACKSON THOMAS ROYSTER

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	P24537

General Provider Information

NPI Number	:	1982567590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON THOMAS ROYSTER

Provider Business Mailing Address
First Line	:	19460 OLD JETTON RD STE 202
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-6763
Country	:	US
Telephone Number	:	704-255-6879
Fax Number	:	704-255-6881

Provider Business Practice Location Address
First Line	:	19460 OLD JETTON RD STE 202
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-6763
Country	:	US
Telephone Number	:	704-255-6879
Fax Number	:	704-255-6881

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

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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Directions to “ JACKSON THOMAS ROYSTER ” Practice Location

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