Healthcare Provider Details

I. General information

NPI: 1003291808
Provider Name (Legal Business Name): JESSE HOLLIDAY P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 GOOD LUCK RD
LANHAM MD
20706-3511
US

IV. Provider business mailing address

5121 LACKAWANNA ST
COLLEGE PARK MD
20740-4530
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-2000
  • Fax:
Mailing address:
  • Phone: 864-607-1615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: