Healthcare Provider Details

I. General information

NPI: 1184876286
Provider Name (Legal Business Name): GERRY E YUTUC OTR, CEAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8855 SAN JOSE BLVD
JACKSONVILLE FL
32217-4244
US

IV. Provider business mailing address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

V. Phone/Fax

Practice location:
  • Phone: 904-448-8191
  • Fax: 904-448-8855
Mailing address:
  • Phone: 904-953-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT5768
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: