Healthcare Provider Details

I. General information

NPI: 1457122012
Provider Name (Legal Business Name): MISTY MARIE JACKSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY MARIE ANDERSON

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 TARN TER
FROSTBURG MD
21532-1242
US

IV. Provider business mailing address

57 JACKSON ST
LONACONING MD
21539-1307
US

V. Phone/Fax

Practice location:
  • Phone: 301-689-1391
  • Fax:
Mailing address:
  • Phone: 240-609-9594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA5057
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: