Provider Demographics
NPI:1033671896
Name:TEAGUE, SUMMER CHRISTIAN
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:CHRISTIAN
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9765 SAN JOSE BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5467
Mailing Address - Country:US
Mailing Address - Phone:904-551-5350
Mailing Address - Fax:904-647-9650
Practice Address - Street 1:9765 SAN JOSE BLVD STE 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5467
Practice Address - Country:US
Practice Address - Phone:904-551-5350
Practice Address - Fax:904-647-9650
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA91601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist