Provider Demographics
NPI:1184968687
Name:JACKSON, LETHECIA (MPT)
Entity type:Individual
Prefix:
First Name:LETHECIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BEVERLY DR SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-3905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:809 S BROAD ST SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4654
Practice Address - Country:US
Practice Address - Phone:706-235-1337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist