Provider Demographics
NPI:1952439259
Name:ANDERSON, JAMIE LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 MANGO TREE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-6707
Mailing Address - Country:US
Mailing Address - Phone:386-428-4548
Mailing Address - Fax:
Practice Address - Street 1:1912 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8345
Practice Address - Country:US
Practice Address - Phone:386-423-1070
Practice Address - Fax:386-423-0780
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19712225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686637Medicare ID - Type Unspecified