Healthcare Provider Details

I. General information

NPI: 1811504541
Provider Name (Legal Business Name): JENNIFER OPALECKY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2020
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PARK PLACE BLVD
DAVENPORT FL
33837-6866
US

IV. Provider business mailing address

104 PARK PLACE BLVD
DAVENPORT FL
33837-6866
US

V. Phone/Fax

Practice location:
  • Phone: 863-547-9793
  • Fax: 863-547-9794
Mailing address:
  • Phone: 863-547-9793
  • Fax: 863-547-9794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.025445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: