Provider Demographics
NPI:1003942111
Name:NIZAMOFF, JACQUELINE KAY (OTR CHT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KAY
Last Name:NIZAMOFF
Suffix:
Gender:F
Credentials:OTR CHT
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:KAY
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:
Practice Address - Street 1:1715 EAGLE HARBOR PKWY STE A
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4324
Practice Address - Country:US
Practice Address - Phone:904-215-6122
Practice Address - Fax:904-375-8627
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2660225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand