MEDICARE: JESSICA MAY CANTU-LANE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2306602886	VA
2	225200000X	Physical Therapy Assistant	6393	TN
3	225200000X	Physical Therapy Assistant	2127726	TX

General Provider Information

NPI Number	:	1043510639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MAY CANTU-LANE PTA

Provider Business Mailing Address
First Line	:	1301 SUMMER LEE DR
Second Line	:
City	:	ROCKWALL
State	:	TX
Zip	:	75032-5452
Country	:	US
Telephone Number	:	972-771-8111
Fax Number	:	972-771-8103

Provider Business Practice Location Address
First Line	:	5618H OX RD
Second Line	:
City	:	FAIRFAX STATION
State	:	VA
Zip	:	22039-1018
Country	:	US
Telephone Number	:	703-426-4949
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2010
Last Update Date	:	03/21/2018

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Directions to “ JESSICA MAY CANTU-LANE PTA” Practice Location

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