Provider Demographics
NPI:1497781132
Name:MICELOTTA, JEANETTE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:
Last Name:MICELOTTA
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 1:12421 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2680
Mailing Address - Country:US
Mailing Address - Phone:904-292-0195
Mailing Address - Fax:904-292-0566
Practice Address - Street 1:12421 SAN JOSE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2680
Practice Address - Country:US
Practice Address - Phone:904-292-0195
Practice Address - Fax:904-292-0566
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY6445XMedicare ID - Type Unspecified