Provider Demographics
NPI:1427321652
Name:PERSON, MARK (PTA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:PERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1509
Mailing Address - Country:US
Mailing Address - Phone:731-298-1848
Mailing Address - Fax:
Practice Address - Street 1:5515 GLEN LAKES DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4309
Practice Address - Country:US
Practice Address - Phone:214-361-8923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-19
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5022314000000X
TX5022314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility