Provider Demographics
NPI:1477189694
Name:JACKSON, SHARI AISHA (LPTA)
Entity Type:Individual
Prefix:
First Name:SHARI
Middle Name:AISHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 WELLSPRING DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-2938
Mailing Address - Country:US
Mailing Address - Phone:540-273-5031
Mailing Address - Fax:
Practice Address - Street 1:3905 DIX ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-1401
Practice Address - Country:US
Practice Address - Phone:202-680-4864
Practice Address - Fax:202-847-3769
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605425225200000X
DCPTA000203225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant