Healthcare Provider Details

I. General information

NPI: 1992149066
Provider Name (Legal Business Name): JOHNETTA JACKSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE
BETHESDA MD
20889-8402
US

IV. Provider business mailing address

9701 MEDICAL CENTER DR
ROCKVILLE MD
20850-3326
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-8842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2691
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: