Provider Demographics
NPI:1114693579
Name:SOUTHERN MAGNOLIA LLC
Entity Type:Organization
Organization Name:SOUTHERN MAGNOLIA LLC
Other - Org Name:SOUTHERN MAGNOLIA LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GEERKEN
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:239-265-5367
Mailing Address - Street 1:17165 JOHN MORRIS RD 291
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908
Mailing Address - Country:US
Mailing Address - Phone:239-265-5367
Mailing Address - Fax:
Practice Address - Street 1:12856 BANYAN CREEK DR # 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3082
Practice Address - Country:US
Practice Address - Phone:239-265-5367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty