Basic Information
| Provider Information | |||||||||
| NPI: | 1326372384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ERICKSON | ||||||||
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| Credential: | PT | ||||||||
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| OtherLastName: | ERICKSON | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 993 CHESTERFIELD PL NW | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300645434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782903944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1431 WHITE CIR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300665801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704269945 | ||||||||
| FaxNumber: | 7704260641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4895 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.