Provider Demographics
NPI:1598826083
Name:JARVIS, MARTHA KATHLEEN (MS PT ATCL)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:KATHLEEN
Last Name:JARVIS
Suffix:
Gender:F
Credentials:MS PT ATCL
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:CABALLERO-JARVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 700097
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34770-0097
Mailing Address - Country:US
Mailing Address - Phone:407-957-6290
Mailing Address - Fax:407-891-9183
Practice Address - Street 1:4237 13TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6732
Practice Address - Country:US
Practice Address - Phone:407-957-6290
Practice Address - Fax:407-891-9183
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10828225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY6091AMedicare ID - Type Unspecified
FLS71658Medicare UPIN