Provider Demographics
NPI:1285103598
Name:GANTT, JERILYN
Entity type:Individual
Prefix:
First Name:JERILYN
Middle Name:
Last Name:GANTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JERILYN
Other - Middle Name:
Other - Last Name:TOUBMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3657 CORTEZ RD W STE 110
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3171
Mailing Address - Country:US
Mailing Address - Phone:941-739-7828
Mailing Address - Fax:941-739-7838
Practice Address - Street 1:3657 CORTEZ RD W STE 110
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3171
Practice Address - Country:US
Practice Address - Phone:941-739-7828
Practice Address - Fax:941-739-7838
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT32760OtherPT LICENSE NUMBER