Basic Information
| Provider Information | |||||||||
| NPI: | 1669866786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MITCHELL-REKRUT | ||||||||
| OtherFirstName: | EMMA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 CREDIT UNION WAY | ||||||||
| Address2: | FL. 3 | ||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 MILL ST | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024764784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816468440 | ||||||||
| FaxNumber: | 7816437542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2015 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 20643 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | S400274054 | 01 | MA | MEDICARE PTAN | OTHER | 110110967A | 05 | MA | MEDICAID |