=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033300322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA MILLER SHERK PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 08/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BOYD ST
-----------------------------------------------------
City | CORNWALL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-507-5311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 W JACKSON AVE
-----------------------------------------------------
City | MYERSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17067-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-866-8881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | TE001849L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------