Provider Demographics
NPI:1053577825
Name:JACKSON, SHAWN E (PT)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 LARSEN RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4863
Mailing Address - Country:US
Mailing Address - Phone:920-883-2284
Mailing Address - Fax:920-884-1026
Practice Address - Street 1:2701 LARSEN RD
Practice Address - Street 2:SUITE 111
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4863
Practice Address - Country:US
Practice Address - Phone:920-883-2284
Practice Address - Fax:920-884-1026
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI#4899-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist