Basic Information
| Provider Information | |||||||||
| NPI: | 1639462492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | JERMAINE | ||||||||
| MiddleName: | LAKEITH | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 708 TREE CROSSINGS PKWY | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352444044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052154239 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 HIGHWAY 304 | ||||||||
| Address2: | |||||||||
| City: | CALERA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350405551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056686800 | ||||||||
| FaxNumber: | 2056682677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2011 | ||||||||
| LastUpdateDate: | 09/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.