Provider Demographics
NPI:1366555211
Name:JACKSON, ERIN HOSIE (MSPT, CPI)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:HOSIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSPT, CPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BANEBERRY
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2147
Mailing Address - Country:US
Mailing Address - Phone:949-716-9616
Mailing Address - Fax:949-494-3222
Practice Address - Street 1:1100 S COAST HWY
Practice Address - Street 2:SUITE 301 B
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2968
Practice Address - Country:US
Practice Address - Phone:949-494-3200
Practice Address - Fax:949-494-3222
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADQ684AOtherMEDICARE PTAN