Provider Demographics
NPI:1821665894
Name:MIXNER, JACK (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MIXNER
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1788 HEMPEL AVE
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-8118
Mailing Address - Country:US
Mailing Address - Phone:407-808-3068
Mailing Address - Fax:
Practice Address - Street 1:1706 E SEMORAN BLVD STE 107
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5610
Practice Address - Country:US
Practice Address - Phone:407-880-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer