Provider Demographics
NPI:1154542678
Name:MARKHAM, JACQUELYN C (RPT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:C
Last Name:MARKHAM
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32743 SCENIC HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-9485
Mailing Address - Country:US
Mailing Address - Phone:352-735-9439
Mailing Address - Fax:
Practice Address - Street 1:600 W NORTH BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5063
Practice Address - Country:US
Practice Address - Phone:352-787-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 1785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist