Individual
MS. ELISE M JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DPT
Contact information
Practice address
601 CHILDRENS LN, NORFOLK, VA 23507-1910
(757) 668-7000
Mailing address
1008 BRANDON AVE, APT 4B, NORFOLK, VA 23507-1153
(757) 668-9015
Taxonomy
Speciality
Code
Description
License number
State
2251P0200X
Pediatric Physical Therapist
Primary
2305206461
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2305206461
VIRGINIA BOARD OF PHYSICAL THERAPY LICENSE
VA
Enumeration date
07/15/2010
Last updated
07/15/2010
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