Provider Demographics
NPI:1649405705
Name:DYER, JESSICA (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DYER
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 1:2245 PLANTATION CENTER DR STE 57
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4311
Mailing Address - Country:US
Mailing Address - Phone:904-374-1414
Mailing Address - Fax:877-736-3470
Practice Address - Street 1:2245 PLANTATION CENTER DR STE 57
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4311
Practice Address - Country:US
Practice Address - Phone:904-374-1414
Practice Address - Fax:877-736-3470
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27842225100000X
GAPT009610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006710800Medicaid