Healthcare Provider Details

I. General information

NPI: 1467724898
Provider Name (Legal Business Name): JACQUELINE COLLIER SWALE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 BURNS AVE
LAKE WALES FL
33853-3314
US

IV. Provider business mailing address

872 TARTAN LOOP
LAKE WALES FL
33853-3582
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax: 205-939-6067
Mailing address:
  • Phone: 615-476-6567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH6264
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT38994
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: