Provider Demographics
NPI:1043510639
Name:CANTU-LANE, JESSICA MAY (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAY
Last Name:CANTU-LANE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 SUMMER LEE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5452
Mailing Address - Country:US
Mailing Address - Phone:972-771-8111
Mailing Address - Fax:972-771-8103
Practice Address - Street 1:5618H OX RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX STATION
Practice Address - State:VA
Practice Address - Zip Code:22039-1018
Practice Address - Country:US
Practice Address - Phone:703-426-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602886225200000X
TN6393225200000X
TX2127726225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant