Provider Demographics
NPI:1457765034
Name:WHITE, DAWN (PTA)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:DEANNE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:4876 WINDERMERE TER
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-4828
Mailing Address - Country:US
Mailing Address - Phone:601-316-7632
Mailing Address - Fax:
Practice Address - Street 1:355 CROSSGATES BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2602
Practice Address - Country:US
Practice Address - Phone:601-316-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4991225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant