Healthcare Provider Details

I. General information

NPI: 1669515607
Provider Name (Legal Business Name): JENNIFER LYNN HAGIST MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14286 BEACH BLVD SUITE 34
JACKSONVILLE FL
32250-1561
US

IV. Provider business mailing address

4247 HIGHWOOD DR
JACKSONVILLE FL
32216-3616
US

V. Phone/Fax

Practice location:
  • Phone: 904-345-7510
  • Fax: 904-345-7540
Mailing address:
  • Phone: 904-345-7510
  • Fax: 904-345-7540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22578
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: