Provider Demographics
NPI:1174129258
Name:KAUFFMAN, JESSICA NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:KAUFFMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 JASPER ST
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-2918
Mailing Address - Country:US
Mailing Address - Phone:808-392-3448
Mailing Address - Fax:
Practice Address - Street 1:1108 AIRPORT BLVD STE C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8623
Practice Address - Country:US
Practice Address - Phone:850-483-0586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21914225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant