Provider Demographics
NPI: | 1891948774 |
---|---|
Name: | JUSTICE, JENNIFER AMANDA (DPT, SCS) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | AMANDA |
Last Name: | JUSTICE |
Suffix: | |
Gender: | F |
Credentials: | DPT, SCS |
Other - Prefix: | |
Other - First Name: | AMY |
Other - Middle Name: | |
Other - Last Name: | PETERSON |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | DPT |
Mailing Address - Street 1: | 2216 GREEN HERON CT |
Mailing Address - Street 2: | |
Mailing Address - City: | FLEMING ISLAND |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32003-8600 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-434-5737 |
Mailing Address - Fax: | 904-560-5283 |
Practice Address - Street 1: | 1525 VIRGILS WAY UNIT 1 |
Practice Address - Street 2: | |
Practice Address - City: | GREEN COVE SPRINGS |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32043-3780 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-657-0089 |
Practice Address - Fax: | 904-560-5283 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-10-23 |
Last Update Date: | 2024-01-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PT28237 | 2251S0007X, 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |