Provider Demographics
NPI:1457122012
Name:JACKSON, MISTY MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:MARIE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:57 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LONACONING
Mailing Address - State:MD
Mailing Address - Zip Code:21539-1307
Mailing Address - Country:US
Mailing Address - Phone:240-609-9594
Mailing Address - Fax:
Practice Address - Street 1:48 TARN TER
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1242
Practice Address - Country:US
Practice Address - Phone:301-689-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant