Healthcare Provider Details

I. General information

NPI: 1124135223
Provider Name (Legal Business Name): KRISTIN I OWEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 BEACH BLVD
JACKSONVILLE FL
32207-4764
US

IV. Provider business mailing address

4712 MARSH HAMMOCK DR W
JACKSONVILLE FL
32224-1858
US

V. Phone/Fax

Practice location:
  • Phone: 904-346-5100
  • Fax: 904-346-5111
Mailing address:
  • Phone: 904-346-5100
  • Fax: 904-346-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: