Healthcare Provider Details

I. General information

NPI: 1184105801
Provider Name (Legal Business Name): JOLIE JOHNSON CARPENTER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N ADAMS ST
QUINCY FL
32351-2404
US

IV. Provider business mailing address

PO BOX 999
MOULTRIE GA
31776-0999
US

V. Phone/Fax

Practice location:
  • Phone: 850-875-0333
  • Fax: 850-875-0335
Mailing address:
  • Phone: 229-985-2080
  • Fax: 229-890-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT33779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: