Provider Demographics
NPI:1467029058
Name:JAQUITH, TIFFANY MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:JAQUITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 CARL SCHURZ DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-2006
Mailing Address - Country:US
Mailing Address - Phone:920-253-5248
Mailing Address - Fax:
Practice Address - Street 1:8449 SW STATE ROAD 200
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481
Practice Address - Country:US
Practice Address - Phone:352-693-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant