Provider Demographics
NPI:1831572411
Name:JERNIGAN, ANDREA (OTR/L)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:LIDDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:945 SW MAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5746
Mailing Address - Country:US
Mailing Address - Phone:386-755-3164
Mailing Address - Fax:386-755-3165
Practice Address - Street 1:945 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5746
Practice Address - Country:US
Practice Address - Phone:386-755-3164
Practice Address - Fax:386-755-3165
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17164225X00000X
FLPT32054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist