Provider Demographics
NPI:1720749039
Name:PREWITT, JEREMY D (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:PREWITT
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 1:3359 MISSION BAY BLVD APT 224
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1972
Mailing Address - Country:US
Mailing Address - Phone:904-735-3565
Mailing Address - Fax:
Practice Address - Street 1:3359 MISSION BAY BLVD APT 224
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-1972
Practice Address - Country:US
Practice Address - Phone:904-735-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28569225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant