Provider Demographics
NPI:1023383825
Name:DANIELS, JESSIE MARIE (LPTA)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:MARIE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 HENTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2917
Mailing Address - Country:US
Mailing Address - Phone:561-689-1799
Mailing Address - Fax:
Practice Address - Street 1:79 HENTHORNE DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-2917
Practice Address - Country:US
Practice Address - Phone:561-689-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA16575172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker