Provider Demographics
NPI:1083320642
Name:COUCH, JERRY G (PTA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:G
Last Name:COUCH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 FAREHAM DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-4477
Mailing Address - Country:US
Mailing Address - Phone:937-824-0660
Mailing Address - Fax:
Practice Address - Street 1:299 FAREHAM DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-4477
Practice Address - Country:US
Practice Address - Phone:937-824-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23311225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant