Healthcare Provider Details

I. General information

NPI: 1134774532
Provider Name (Legal Business Name): JESSE MICHAEL ZIMMER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2019
Last Update Date: 08/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 W LUMSDEN RD
BRANDON FL
33511-6280
US

IV. Provider business mailing address

11423 DRIFTING LEAF DR
RIVERVIEW FL
33579-0002
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-8998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA29393
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: