Provider Demographics
NPI:1255700555
Name:ACTION JACKSON PHYSICAL THERAPY, P.C.
Entity type:Organization
Organization Name:ACTION JACKSON PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:LORAN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:510-292-5385
Mailing Address - Street 1:1005 SOLANO AVE
Mailing Address - Street 2:APT. A
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1617
Mailing Address - Country:US
Mailing Address - Phone:510-292-5385
Mailing Address - Fax:
Practice Address - Street 1:2844 SUMMIT ST
Practice Address - Street 2:SUITE 106
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3637
Practice Address - Country:US
Practice Address - Phone:510-763-3005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty