MEDICARE: JACK FLETCHER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	42156	FL

General Provider Information

NPI Number	:	1023849387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK FLETCHER

Provider Business Mailing Address
First Line	:	5732 CLIFTON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-6973
Country	:	US
Telephone Number	:	904-248-9928
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 13TH AVE S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-5024
Country	:	US
Telephone Number	:	904-853-5106
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2024
Last Update Date	:	08/09/2024

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Directions to “ JACK FLETCHER ” Practice Location

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