Healthcare Provider Details

I. General information

NPI: 1962603035
Provider Name (Legal Business Name): JEANNIE WELLS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3599 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4252
US

IV. Provider business mailing address

5852 PAVILION DR
JACKSONVILLE FL
32258-5477
US

V. Phone/Fax

Practice location:
  • Phone: 904-858-7643
  • Fax:
Mailing address:
  • Phone: 904-262-7702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT17859
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: