Basic Information
| Provider Information | |||||||||
| NPI: | 1538518808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BICKERSTAFF | ||||||||
| FirstName: | CHRISTEN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 SOUTH PARK BLVD. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ST. AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048241478 | ||||||||
| FaxNumber: | 9048248071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 31426 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.