Provider Demographics
NPI:1720069065
Name:STEVENS, GERALD ALLEN (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:ALLEN
Last Name:STEVENS
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1613
Mailing Address - Country:US
Mailing Address - Phone:904-880-2424
Mailing Address - Fax:904-880-2420
Practice Address - Street 1:11945 SAN JOSE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1613
Practice Address - Country:US
Practice Address - Phone:904-880-2424
Practice Address - Fax:904-880-2420
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 4282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL 428OtherSTATE LICENSE