Provider Demographics
NPI:1497157622
Name:JOHNSON, HEATHER ROXANN (PT)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ROXANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13810 SUTTON PARK DR N
Mailing Address - Street 2:632
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-4237
Mailing Address - Country:US
Mailing Address - Phone:904-566-8968
Mailing Address - Fax:
Practice Address - Street 1:13810 SUTTON PARK DR N
Practice Address - Street 2:632
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-4237
Practice Address - Country:US
Practice Address - Phone:904-566-8968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist