Healthcare Provider Details

I. General information

NPI: 1184066771
Provider Name (Legal Business Name): JOHNNETHEL M FORT OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 NORMANDY BLVD
JACKSONVILLE FL
32221-6701
US

IV. Provider business mailing address

1065 PEBBLE RIDGE DR
JACKSONVILLE FL
32220-1323
US

V. Phone/Fax

Practice location:
  • Phone: 904-783-3749
  • Fax:
Mailing address:
  • Phone: 904-343-1441
  • Fax: 904-786-2813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License NumberOT10738
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: