Provider Demographics
NPI:1962888495
Name:JACKSON, FAUNICE REBECCA (DPT, PT)
Entity type:Individual
Prefix:
First Name:FAUNICE
Middle Name:REBECCA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 TARRYTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2515
Mailing Address - Country:US
Mailing Address - Phone:703-336-2762
Mailing Address - Fax:
Practice Address - Street 1:1625 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3683
Practice Address - Country:US
Practice Address - Phone:703-558-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT872732225100000X
MD25603225100000X
VA2305211720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist