Provider Demographics
NPI:1508115544
Name:JACQUES, PAMELA R (PTA)
Entity Type:Individual
Prefix:MISS
First Name:PAMELA
Middle Name:R
Last Name:JACQUES
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 1:5791 49TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2107
Mailing Address - Country:US
Mailing Address - Phone:727-527-2100
Mailing Address - Fax:
Practice Address - Street 1:8701 BLIND PASS RD
Practice Address - Street 2:305B
Practice Address - City:ST PETE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33706-1465
Practice Address - Country:US
Practice Address - Phone:727-360-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 23366225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant