Provider Demographics
NPI:1326372384
Name:BUSS, JACQUELINE ERICKSON (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ERICKSON
Last Name:BUSS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:993 CHESTERFIELD PL NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5434
Mailing Address - Country:US
Mailing Address - Phone:678-290-3944
Mailing Address - Fax:
Practice Address - Street 1:1431 WHITE CIR
Practice Address - Street 2:SUITE C
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-5801
Practice Address - Country:US
Practice Address - Phone:770-426-9945
Practice Address - Fax:770-426-0641
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT4895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist