Healthcare Provider Details

I. General information

NPI: 1548852197
Provider Name (Legal Business Name): ALEXANDRA HENDERSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1553
US

IV. Provider business mailing address

11945 SAN JOSE BLVD STE 300
JACKSONVILLE FL
32223-1627
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-1725
  • Fax: 904-396-4893
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-396-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT36633
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: