Provider Demographics
NPI:1689476368
Name:JACQUES, TASHEENA (PT, DPT)
Entity type:Individual
Prefix:
First Name:TASHEENA
Middle Name:
Last Name:JACQUES
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 WYNTHROPE WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-5134
Mailing Address - Country:US
Mailing Address - Phone:978-495-6493
Mailing Address - Fax:
Practice Address - Street 1:560 THORNTON RD STE 200
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1656
Practice Address - Country:US
Practice Address - Phone:770-739-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist