Provider Demographics
NPI:1881945954
Name:JACKSON, VERA K
Entity type:Individual
Prefix:
First Name:VERA
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34921 US HIGHWAY 19 N
Mailing Address - Street 2:450
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1969
Mailing Address - Country:US
Mailing Address - Phone:800-251-8998
Mailing Address - Fax:
Practice Address - Street 1:34921 US HIGHWAY 19 N
Practice Address - Street 2:450
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1969
Practice Address - Country:US
Practice Address - Phone:800-251-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant