Provider Demographics
NPI:1720169402
Name:JARRETT, DOMINIQUE (MPT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:JARRETT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 CYNWOOD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3805
Mailing Address - Country:US
Mailing Address - Phone:410-770-9720
Mailing Address - Fax:410-770-9725
Practice Address - Street 1:598 CYNWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3805
Practice Address - Country:US
Practice Address - Phone:410-770-9720
Practice Address - Fax:410-770-9725
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP17331Medicare UPIN