Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist |
NPI | 1124441621 |
---|---|
Provider Name | Mr. Henry Edward Jackson |
First Address | Richmond, VA 23220 |
Second Address | Richmond, VA 23220 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2014 |
Last Update Date | 04/02/2014 |