Active NPI
Jacob S Jackson, DPT
- Physical Therapist
- Mount Vernon, IL
National Provider Identifier
1982162905
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 070024163
- Practice address
- 4110 S Water Tower PL
Mount Vernon, IL 62864-6544 - Phone
- (618) 242-1100
- Fax
- (618) 244-5148
- NPI assigned
- Mar 8, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 070024163 | IL | Primary |
Addresses
Primary practice location
4110 S Water Tower PL
Mount Vernon, IL 62864-6544
Mailing address
4110 S Water Tower PL
Mount Vernon, IL 62864-6544
Phone (618) 242-1100
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 070024163 | IL | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1552003200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1552003200000",
"number": "1982162905",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4110 S WATER TOWER PL",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628646544",
"telephone_number": "618-242-1100",
"fax_number": "618-244-5148"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4110 S WATER TOWER PL",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628646544",
"telephone_number": "618-242-1100",
"fax_number": "618-244-5148"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "JACOB",
"middle_name": "S",
"name_prefix": "Mr.",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-03-08",
"last_updated": "2019-03-08",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "IL",
"license": "070024163",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Mount Vernon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.