Provider Demographics
NPI:1619338092
Name:TICZON, JUSETTE ESPULGAR
Entity Type:Individual
Prefix:MRS
First Name:JUSETTE
Middle Name:ESPULGAR
Last Name:TICZON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 W SAMPLE RD
Mailing Address - Street 2:APT. 304
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3248
Mailing Address - Country:US
Mailing Address - Phone:954-234-4847
Mailing Address - Fax:954-942-1130
Practice Address - Street 1:5900 W SAMPLE RD
Practice Address - Street 2:APT. 304
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-3248
Practice Address - Country:US
Practice Address - Phone:954-234-4847
Practice Address - Fax:954-942-1130
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist