Provider Demographics
NPI:1164869814
Name:METCALF, JACKSON HOWISON JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:HOWISON
Last Name:METCALF
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4920 WOODMAR DR SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1651
Mailing Address - Country:US
Mailing Address - Phone:540-400-0897
Mailing Address - Fax:540-400-0904
Practice Address - Street 1:4920 WOODMAR DR SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1651
Practice Address - Country:US
Practice Address - Phone:540-400-0897
Practice Address - Fax:540-400-0904
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001021225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant