Provider Demographics
NPI:1508113754
Name:WATSON, JESSICA SHANNON (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHANNON
Last Name:WATSON
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 1:463 SW MULESKINNER CT
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-1133
Mailing Address - Country:US
Mailing Address - Phone:352-339-0872
Mailing Address - Fax:
Practice Address - Street 1:404 NW HALL OF FAME DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4833
Practice Address - Country:US
Practice Address - Phone:386-755-3163
Practice Address - Fax:386-755-3165
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22089225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant