Provider Demographics
NPI:1598291262
Name:SLATER, JACQUELINE (PTA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:SLATER
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 1:2500 TAMIAMI TRL N STE 222
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-4470
Mailing Address - Country:US
Mailing Address - Phone:239-649-8001
Mailing Address - Fax:239-649-8003
Practice Address - Street 1:12975 COLLIER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-4004
Practice Address - Country:US
Practice Address - Phone:239-649-8001
Practice Address - Fax:239-649-8003
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27049225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant