1306134267 NPI number — DAILE M JACKSON PT, DPT

Table of content: DAILE M JACKSON PT, DPT (NPI 1306134267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306134267 NPI number — DAILE M JACKSON PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
DAILE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
DAILE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306134267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3266 FLUVANNA AVENUE EXT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLUVANNA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14701-9706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-665-0773
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
774 FAIRMOUNT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14701-2609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-665-1166
Provider Business Practice Location Address Fax Number:
866-902-1160
Provider Enumeration Date:
07/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  033817-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03424691 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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