MEDICARE: JIRDELLE JEAN-LOUIS PTA

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
1	225200000X	Physical Therapy Assistant	PTA 22397	FL

General Provider Information

NPI Number	:	1841570389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIRDELLE JEAN-LOUIS PTA

Provider Business Mailing Address
First Line	:	745 NW 134TH ST
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33168-2824
Country	:	US
Telephone Number	:	786-553-7750
Fax Number	:

Provider Business Practice Location Address
First Line	:	745 NW 134TH ST
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33168-2824
Country	:	US
Telephone Number	:	786-553-7750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2011
Last Update Date	:	08/26/2011

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