Provider Demographics
NPI:1508635269
Name:PRINCE, JESSICA LEE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:PRINCE
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 1:3344 GONDOLIER WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33462-3622
Mailing Address - Country:US
Mailing Address - Phone:407-687-2154
Mailing Address - Fax:
Practice Address - Street 1:3344 GONDOLIER WAY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33462-3622
Practice Address - Country:US
Practice Address - Phone:407-687-2154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28695225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty