Basic Information
| Provider Information | |||||||||
| NPI: | 1003942111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIZAMOFF | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR CHT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUTLER | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1715 EAGLE HARBOR PKWY STE A | ||||||||
| Address2: | |||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042156122 | ||||||||
| FaxNumber: | 9043758627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 2660 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
No ID Information.