Provider Demographics
NPI:1235960279
Name:ANDERSON, JADEN NICOLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JADEN
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12359 SUNCHASE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4215
Mailing Address - Country:US
Mailing Address - Phone:386-690-8166
Mailing Address - Fax:
Practice Address - Street 1:463155 SR 200
Practice Address - Street 2:UNIT 12
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097
Practice Address - Country:US
Practice Address - Phone:904-849-1625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT41695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist