Provider Demographics
NPI:1508449000
Name:JAGANATHAN, GERALDINE JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:JESSICA
Last Name:JAGANATHAN
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 1:7808 CHAPEL COVE DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5843
Mailing Address - Country:US
Mailing Address - Phone:301-613-7222
Mailing Address - Fax:
Practice Address - Street 1:3200 CRAIN HWY STE 103
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4841
Practice Address - Country:US
Practice Address - Phone:240-419-5101
Practice Address - Fax:240-419-5106
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5506225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant