Provider Demographics
NPI:1003291808
Name:HOLLIDAY, JESSE (PTA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:HOLLIDAY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 LACKAWANNA ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-4530
Mailing Address - Country:US
Mailing Address - Phone:864-607-1615
Mailing Address - Fax:
Practice Address - Street 1:8200 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3511
Practice Address - Country:US
Practice Address - Phone:301-552-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant