Healthcare Provider Details

I. General information

NPI: 1598408254
Provider Name (Legal Business Name): JESSICA SCHUPBACH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12429 SCOFIELD FARMS DR
AUSTIN TX
78758-2640
US

IV. Provider business mailing address

100 GRASON RD
GLEN BURNIE MD
21061-4534
US

V. Phone/Fax

Practice location:
  • Phone: 512-835-9080
  • Fax:
Mailing address:
  • Phone: 240-499-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4308
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: