Provider Demographics
NPI:1396357067
Name:STACKHOUSE, JANA LEA (PTA)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:LEA
Last Name:STACKHOUSE
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 1:1000 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-2600
Mailing Address - Country:US
Mailing Address - Phone:570-784-1896
Mailing Address - Fax:570-784-1897
Practice Address - Street 1:1000 MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-2600
Practice Address - Country:US
Practice Address - Phone:570-784-1896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000628225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty