Provider Demographics
NPI:1669515607
Name:HAGIST, JENNIFER LYNN (MPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:HAGIST
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 HIGHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3616
Mailing Address - Country:US
Mailing Address - Phone:904-345-7510
Mailing Address - Fax:904-345-7540
Practice Address - Street 1:14286 BEACH BLVD
Practice Address - Street 2:SUITE 34
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-1561
Practice Address - Country:US
Practice Address - Phone:904-345-7510
Practice Address - Fax:904-345-7540
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22578225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891374900Medicaid