Provider Demographics
NPI:1366535551
Name:LUTZYK, JENNIFER A (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:LUTZYK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1075 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4611
Mailing Address - Country:US
Mailing Address - Phone:386-255-4596
Mailing Address - Fax:386-258-3561
Practice Address - Street 1:1075 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:386-255-4596
Practice Address - Fax:386-258-3561
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT153892251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1284AMedicare PIN