Provider Demographics
NPI:1568706406
Name:KETTLES, MEGHAN E (PT)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:E
Last Name:KETTLES
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 1:1325 SAN MARCO BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8568
Mailing Address - Country:US
Mailing Address - Phone:904-858-7045
Mailing Address - Fax:904-858-7047
Practice Address - Street 1:12961 N MAIN ST
Practice Address - Street 2:SUITE 201 & 202
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2769
Practice Address - Country:US
Practice Address - Phone:904-757-2474
Practice Address - Fax:904-757-5541
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist