Healthcare Provider Details

I. General information

NPI: 1295293652
Provider Name (Legal Business Name): JAREB C LANDON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

IV. Provider business mailing address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4596
  • Fax: 386-257-0558
Mailing address:
  • Phone: 386-255-4596
  • Fax: 386-257-0558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT-34078
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-34078
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT6215
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: