Provider Demographics
NPI:1366610990
Name:RICKETSON, JOSEPH LEE (DPT)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:LEE
Last Name:RICKETSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 PAW PAW LN
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-3182
Mailing Address - Country:US
Mailing Address - Phone:229-563-5085
Mailing Address - Fax:229-890-3397
Practice Address - Street 1:4274 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6814
Practice Address - Country:US
Practice Address - Phone:229-241-9288
Practice Address - Fax:229-241-9443
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013328225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT013328OtherPT BOARD
GAPTA002445OtherPT BOARD