Individual
KEITH JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MPT
Contact information
Practice address
1812 MARSH RD, STORE 505, WILMINGTON, DE 19810-4581
(302) 475-7500
Mailing address
790 REMINGTON BLVD, BOLINGBROOK, IL 60440-4909
(630) 296-2223
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
21348
MD
225100000X
Physical Therapist
Primary
J1-0001883
DE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1530795
PABS
—
01
—
2342330000
AMERIHEALTH
—
01
—
246555
MAMSI
—
01
—
5070-0032
NCA
—
01
—
50700032
CAREFIRST
—
01
—
64343601
CARE FIRST
—
Enumeration date
06/28/2006
Last updated
09/19/2013
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