Provider Demographics
NPI:1184066771
Name:FORT, JOHNNETHEL M (OTR/L)
Entity type:Individual
Prefix:MS
First Name:JOHNNETHEL
Middle Name:M
Last Name:FORT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1065 PEBBLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32220-1323
Mailing Address - Country:US
Mailing Address - Phone:904-343-1441
Mailing Address - Fax:904-786-2813
Practice Address - Street 1:8495 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-6701
Practice Address - Country:US
Practice Address - Phone:904-783-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10738225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology