Basic Information
| Provider Information | |||||||||
| NPI: | 1124135223 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | OWEN | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4712 MARSH HAMMOCK DR W | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322241858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043465100 | ||||||||
| FaxNumber: | 9043465111 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322074764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043465100 | ||||||||
| FaxNumber: | 9043465111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT6722 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 15880738800 | 05 | FL | MEDICAID |