Provider Demographics
NPI:1679547269
Name:JACKSON, DAVID ANDREW (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
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 1:326 N INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-1223
Mailing Address - Country:US
Mailing Address - Phone:812-246-8975
Mailing Address - Fax:812-246-8977
Practice Address - Street 1:326 N INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-1223
Practice Address - Country:US
Practice Address - Phone:812-246-8975
Practice Address - Fax:812-246-8977
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000042777OtherANTHEM PIN #
IN64-00191OtherUHC PIN #
IN137550Medicare PIN