Provider Demographics
NPI:1679877849
Name:AVILA, JESSIELYNN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JESSIELYNN
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 W 84TH ST
Mailing Address - Street 2:#58
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3377
Mailing Address - Country:US
Mailing Address - Phone:305-985-6122
Mailing Address - Fax:786-545-7657
Practice Address - Street 1:1550 W 84TH ST
Practice Address - Street 2:#58
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3377
Practice Address - Country:US
Practice Address - Phone:305-985-6122
Practice Address - Fax:786-545-7657
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT261382251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003271100Medicaid