Provider Demographics
NPI:1669728499
Name:JACQUAY, ANDREW T (DPT)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:T
Last Name:JACQUAY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13401 SUTTON PARK DR S
Mailing Address - Street 2:APT #714
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-5266
Mailing Address - Country:US
Mailing Address - Phone:859-250-5061
Mailing Address - Fax:
Practice Address - Street 1:31 LUPI CT
Practice Address - Street 2:SUITE 150
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4761
Practice Address - Country:US
Practice Address - Phone:386-447-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
34123111Medicare PIN