Active NPI
Wayne Jackson, DPT
- Physical Therapist
- Ellicott City, MD
National Provider Identifier
1104204668
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 25338
- Practice address
- 10300B Baltimore National Pike
Ellicott City, MD 21042-2128 - Phone
- (410) 988-5171
- Fax
- (410) 988-5349
- NPI assigned
- May 15, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 25338 | MD | Primary |
Addresses
Primary practice location
10300B Baltimore National Pike
Ellicott City, MD 21042-2128
Mailing address
10300-B Baltimore National Pike
Ellicott City, MD 21042-2128
Phone (410) 988-5171
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 25338 | MD | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1431648000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1449187200000",
"number": "1104204668",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10300-B BALTIMORE NATIONAL PIKE",
"city": "ELLICOTT CITY",
"state": "MD",
"postal_code": "210422128",
"telephone_number": "410-988-5171",
"fax_number": "410-988-5349"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10300B BALTIMORE NATIONAL PIKE",
"city": "ELLICOTT CITY",
"state": "MD",
"postal_code": "210422128",
"telephone_number": "410-988-5171",
"fax_number": "410-988-5349"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "WAYNE",
"name_prefix": "Dr.",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-05-15",
"last_updated": "2015-12-04",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "MD",
"license": "25338",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Ellicott City, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.