Provider Demographics
NPI:1568790475
Name:BARRETT, JESSICA AMANDA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:AMANDA
Last Name:BARRETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:AMANDA
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:4240 LAKELAND HIGHLANDS RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3113
Mailing Address - Country:US
Mailing Address - Phone:863-607-5948
Mailing Address - Fax:
Practice Address - Street 1:4240 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3113
Practice Address - Country:US
Practice Address - Phone:863-607-5948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21002225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant