Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist |
NPI | 1528174109 |
---|---|
Provider Name | Mrs. Charlene Dawn Jackson |
First Address | Augusta, GA 30904-6258 |
Second Address | Augusta, GA 30904-6258 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2006 |
Last Update Date | 08/07/2007 |