Basic Information
| Provider Information | |||||||||
| NPI: | 1568706406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETTLES | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 SAN MARCO BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048587045 | ||||||||
| FaxNumber: | 9048587047 | ||||||||
| Practice Location | |||||||||
| Address1: | 12961 N MAIN ST | ||||||||
| Address2: | SUITE 201 & 202 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322182769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047572474 | ||||||||
| FaxNumber: | 9047575541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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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 | PT27640 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.