Provider Demographics
NPI:1841689155
Name:JACKSON, MEGAN LEE (PTA)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:LEE
Last Name:JACKSON
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 1:718 WOLF BRANCH CIR
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-7328
Mailing Address - Country:US
Mailing Address - Phone:843-506-5123
Mailing Address - Fax:
Practice Address - Street 1:718 WOLF BRANCH CIR
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-7328
Practice Address - Country:US
Practice Address - Phone:843-506-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPTA.3235 PTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant