Provider Demographics
NPI:1871526574
Name:UTTERBACK, JEANNE (PT)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 WOODMERE PARK BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5373
Mailing Address - Country:US
Mailing Address - Phone:941-408-0670
Mailing Address - Fax:941-408-0160
Practice Address - Street 1:4120 WOODMERE PARK BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5373
Practice Address - Country:US
Practice Address - Phone:941-408-0670
Practice Address - Fax:941-408-0160
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
106970Medicare ID - Type Unspecified
1447251947Medicare UPIN