Provider Demographics
NPI:1104058965
Name:LAFALCE, JESSICA LYNNE (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:LAFALCE
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 1:22258 ELMIRA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8413
Mailing Address - Country:US
Mailing Address - Phone:941-204-1051
Mailing Address - Fax:
Practice Address - Street 1:5901 BROKEN SOUND PKWY STE 500
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2791
Practice Address - Country:US
Practice Address - Phone:800-875-8999
Practice Address - Fax:561-417-7443
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20971225200000X
CA9059225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant