Basic Information
| Provider Information | |||||||||
| NPI: | 1811260052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JEANNA | ||||||||
| MiddleName: | PATRICE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 IRVING ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028771566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2021 K ST NW | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200061003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022931853 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2012 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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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 | 871328 | DC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305209240 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 23935 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.