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Individual
MATTHEW JACKSON
Active
Individual
MATTHEW JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPT, MOT,ATC
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
07464
LA
2255A2300X
Athletic Trainer
Primary
07464
LA
225X00000X
Occupational Therapist
07464
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
07464
LA STATE LICENSE
LA
Enumeration date
02/22/2010
Last updated
02/22/2010
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