Healthcare Provider Details

I. General information

NPI: 1306109582
Provider Name (Legal Business Name): JESSICA LEE MASH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3456 BEALE AVE
ALTOONA PA
16601-1312
US

IV. Provider business mailing address

3456 BEALE AVE
ALTOONA PA
16601-1312
US

V. Phone/Fax

Practice location:
  • Phone: 814-932-5632
  • Fax:
Mailing address:
  • Phone: 814-932-5632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberTE1002166
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: