Provider Demographics
NPI:1164430781
Name:ZIMMERMAN, COREY JASON (MPT)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:JASON
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6454 GINNIE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5102
Mailing Address - Country:US
Mailing Address - Phone:904-477-6462
Mailing Address - Fax:
Practice Address - Street 1:5939 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244
Practice Address - Country:US
Practice Address - Phone:904-412-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0244811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892311600Medicaid