Healthcare Provider Details

I. General information

NPI: 1366803892
Provider Name (Legal Business Name): YOKO HIROSE JACKSON P.T.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11625 MANDEVILLA VIEW WAY
RIVERVIEW FL
33579-1819
US

IV. Provider business mailing address

11625 MANDEVILLA VIEW WAY
RIVERVIEW FL
33579-1819
US

V. Phone/Fax

Practice location:
  • Phone: 727-518-5177
  • Fax:
Mailing address:
  • Phone: 727-518-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA25045
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: