Provider Demographics
NPI:1568911071
Name:JACKSON, TIPHANI (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:TIPHANI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11120 SUPERIOR LNDG
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3491
Mailing Address - Country:US
Mailing Address - Phone:301-412-9552
Mailing Address - Fax:
Practice Address - Street 1:4000 MITCHELLVILLE RD # B222B224
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3104
Practice Address - Country:US
Practice Address - Phone:301-412-9552
Practice Address - Fax:301-500-2175
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2023-02-28
Deactivation Date:2018-09-01
Deactivation Code:
Reactivation Date:2018-09-19
Provider Licenses
StateLicense IDTaxonomies
MD27375225100000X, 225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program