Healthcare Provider Details

I. General information

NPI: 1164040952
Provider Name (Legal Business Name): EMILY ANASTASYA JACKSON PT, DPT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22505 LANDMARK CT # 215
ASHBURN VA
20148-6500
US

IV. Provider business mailing address

3035 BOONE TRAIL EXT STE A
FAYETTEVILLE NC
28304-3860
US

V. Phone/Fax

Practice location:
  • Phone: 703-726-1616
  • Fax:
Mailing address:
  • Phone: 910-900-3814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-6216
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP24684
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: