Provider Demographics
NPI:1982322566
Name:RICHARD, JESSICA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:RICHARD
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 1:1309 KEYSTONE PT
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-2360
Mailing Address - Country:US
Mailing Address - Phone:863-398-9085
Mailing Address - Fax:
Practice Address - Street 1:330 AVENUE C SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3243
Practice Address - Country:US
Practice Address - Phone:863-268-2903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25955225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant