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NPI Code Detail

MEDICARE: MS. JOHNNETHEL M FORT OTR/L

MEDICARE: MS. JOHNNETHEL M FORT OTR/L
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225XG0600XGerontology Occupational TherapistOT10738FL

General Provider Information

NPI Number : 1184066771
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JOHNNETHEL M FORT OTR/L
Provider Business Mailing Address
First Line : 1065 PEBBLE RIDGE DR
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32220-1323
Country : US
Telephone Number : 904-343-1441
Fax Number : 904-786-2813
Provider Business Practice Location Address
First Line : 8495 NORMANDY BLVD
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32221-6701
Country : US
Telephone Number : 904-783-3749
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/23/2013
Last Update Date : 07/23/2013

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