Healthcare Provider Details

I. General information

NPI: 1750153615
Provider Name (Legal Business Name): SOL JOHANNA JAQUE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 SWANSON AVE STE 102
LAKE HAVASU CITY AZ
86403-6699
US

IV. Provider business mailing address

191 SWANSON AVE STE 102
LAKE HAVASU CITY AZ
86403-6699
US

V. Phone/Fax

Practice location:
  • Phone: 928-855-7880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-014722
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: