Healthcare Provider Details

I. General information

NPI: 1447882139
Provider Name (Legal Business Name): JILL MARIE BAXTER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 DUNN AVE
DAYTONA BEACH FL
32114-2405
US

IV. Provider business mailing address

912 ASHMEADE CT
PORT ORANGE FL
32127-7943
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number29658
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: