Provider Demographics
NPI:1831572411
Name:JERNIGAN, ANDREA (DPT)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:LIDDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9070 W CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8934
Mailing Address - Country:US
Mailing Address - Phone:702-268-7213
Mailing Address - Fax:
Practice Address - Street 1:945 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5746
Practice Address - Country:US
Practice Address - Phone:386-755-3164
Practice Address - Fax:386-755-3165
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32054225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist