Healthcare Provider Details

I. General information

NPI: 1831572411
Provider Name (Legal Business Name): ANDREA JERNIGAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA LIDDELL

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 SW MAIN BLVD
LAKE CITY FL
32025-5746
US

IV. Provider business mailing address

9070 W CHEYENNE AVE
LAS VEGAS NV
89129-8934
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3164
  • Fax: 386-755-3165
Mailing address:
  • Phone: 702-268-7213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: