Provider Demographics
NPI:1144766049
Name:JIMMERSON, NATHAN (PTA)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:JIMMERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 LINWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4235
Mailing Address - Country:US
Mailing Address - Phone:813-784-4830
Mailing Address - Fax:
Practice Address - Street 1:319 W TOWN PL
Practice Address - Street 2:WORLD GOLF VILLAGE, SUITE 5
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3101
Practice Address - Country:US
Practice Address - Phone:904-342-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 27099225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant