Healthcare Provider Details

I. General information

NPI: 1972289841
Provider Name (Legal Business Name): JASMINE NICOLE LHOTKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14545 W. INDIAN SCHOOL RD.
GOODYEAR AZ
85338
US

IV. Provider business mailing address

15400 WEST GOODYEAR BLVD N. 245
GOODYEAR AZ
85338
US

V. Phone/Fax

Practice location:
  • Phone: 623-335-3736
  • Fax:
Mailing address:
  • Phone: 623-570-5316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number33056
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: