=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497201198
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA GOETZ PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 09/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 459 KM13.1 CALLE LAS UVAS INT.
-----------------------------------------------------
City | ISABELA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-244-6853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2096
-----------------------------------------------------
City | ISABELA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00662-9096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-244-6853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1359
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------