Provider Demographics
NPI:1134774532
Name:ZIMMER, JESSE MICHAEL (PTA)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:MICHAEL
Last Name:ZIMMER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11423 DRIFTING LEAF DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:851 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6280
Practice Address - Country:US
Practice Address - Phone:813-661-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-03
Last Update Date:2019-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29393225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant