Provider Demographics
NPI:1508262734
Name:STACK, MARY JEAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:MARY JEAN
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 WALKER RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-2650
Mailing Address - Country:US
Mailing Address - Phone:202-349-1030
Mailing Address - Fax:703-364-5124
Practice Address - Street 1:766 WALKER RD STE B
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:VA
Practice Address - Zip Code:22066-2650
Practice Address - Country:US
Practice Address - Phone:202-349-1030
Practice Address - Fax:703-364-5124
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508262734OtherNPI
DCPT872017OtherLICENSE