Provider Demographics
NPI:1720454085
Name:BURKHOLDER, ZACKERY LAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:ZACKERY
Middle Name:LAYNE
Last Name:BURKHOLDER
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 1:10961 BURNT MILL RD APT 923
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-4667
Mailing Address - Country:US
Mailing Address - Phone:863-832-3312
Mailing Address - Fax:
Practice Address - Street 1:36261 OKEFENOKEE DR
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-7853
Practice Address - Country:US
Practice Address - Phone:912-496-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25917225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant