Provider Demographics
NPI:1013435833
Name:MIMMS, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MIMMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 N PARK AVE UNIT 145
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32704-8607
Mailing Address - Country:US
Mailing Address - Phone:407-335-0360
Mailing Address - Fax:
Practice Address - Street 1:305 E OAK ST
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4352
Practice Address - Country:US
Practice Address - Phone:407-335-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant