Individual
MS. CAROL JEAN JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T.
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT17651
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20-0700404
TAX I.D. # FOR FACILITY
CA
01
—
OPT176510
BLUE SHIELD
CA
Enumeration date
06/14/2005
Last updated
05/21/2010
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