Provider Demographics
NPI:1114335759
Name:RICHARDSON, JEREMY (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:RICHARDSON
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 1:4148 RIDGEMOOR DR N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-1152
Mailing Address - Country:US
Mailing Address - Phone:727-385-6579
Mailing Address - Fax:
Practice Address - Street 1:4148 RIDGEMOOR DR N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-1152
Practice Address - Country:US
Practice Address - Phone:727-385-6579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25002225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant