Provider Demographics
NPI:1770797292
Name:DICKERSON, MARTHA JARMON (PTA)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JARMON
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 TOMAHAWK CIR
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-7747
Mailing Address - Country:US
Mailing Address - Phone:256-505-0268
Mailing Address - Fax:
Practice Address - Street 1:5275 MILLENNIUM DR NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-2457
Practice Address - Country:US
Practice Address - Phone:256-489-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA3896225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant