Basic Information
| Provider Information | |||||||||
| NPI: | 1730279100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ARLYN | ||||||||
| MiddleName: | RIVERA | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 12TH ST | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320841413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043775559 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 NATURE WALK PARKWAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042307761 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PT20823 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.