Healthcare Provider Details

I. General information

NPI: 1215539861
Provider Name (Legal Business Name): JAKIERRA OATES LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7122 SE 216TH TER
HAWTHORNE FL
32640-3981
US

IV. Provider business mailing address

PO BOX 281
WELAKA FL
32193-0281
US

V. Phone/Fax

Practice location:
  • Phone: 352-318-8759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number95119
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: