Active NPI
Matilda Nelms Jackson, PTA
- Physical Therapy Assistant
- Vidalia, GA
National Provider Identifier
1821210907
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 000664
- Practice address
- 136 Kendall Palmer Rd
Vidalia, GA 30474-8200 - Phone
- (912) 538-9832
- NPI assigned
- May 2, 2007
- Sex
- Female
- 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 Therapy Assistant | 225200000X | 000664 | GA | Primary |
Addresses
Primary practice location
136 Kendall Palmer Rd
Vidalia, GA 30474-8200
Mailing address
136 Kendall Palmer Rd
Vidalia, GA 30474-8200
Phone (912) 538-9832
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 000664 | Other | GA | PTA |
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)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 000664 | GA | MD | Medical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1178064000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1821210907",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "136 KENDALL PALMER RD",
"city": "VIDALIA",
"state": "GA",
"postal_code": "304748200",
"telephone_number": "912-538-9832"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "136 KENDALL PALMER RD",
"city": "VIDALIA",
"state": "GA",
"postal_code": "304748200",
"telephone_number": "912-538-9832"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "MATILDA",
"middle_name": "NELMS",
"name_prefix": "Mrs.",
"credential": "PTA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-05-02",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "GA",
"license": "000664",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PTA",
"identifier": "000664",
"state": "GA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Vidalia, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.