Basic Information
| Provider Information | |||||||||
| NPI: | 1821068180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | HOLST | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5718 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599035718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067560134 | ||||||||
| FaxNumber: | 4063001612 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 N CENTER ST STE 5 | ||||||||
| Address2: | |||||||||
| City: | LONOKE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720862100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016765540 | ||||||||
| FaxNumber: | 5016766499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT1452 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 127082721 | 05 | AR | MEDICAID |