Provider Demographics
NPI:1144888678
Name:TOBOSO, JED DELLUMES (PT)
Entity type:Individual
Prefix:MR
First Name:JED
Middle Name:DELLUMES
Last Name:TOBOSO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 PATRIOT COMMONS RD
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-4709
Mailing Address - Country:US
Mailing Address - Phone:662-770-9804
Mailing Address - Fax:
Practice Address - Street 1:24151 BEATRIX BLVD UNIT 1107
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-3864
Practice Address - Country:US
Practice Address - Phone:662-770-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty