Provider Demographics
NPI:1053020842
Name:GILLIS, JAKE LEY (DPT)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:LEY
Last Name:GILLIS
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 1:7230 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5430
Mailing Address - Country:US
Mailing Address - Phone:954-907-3182
Mailing Address - Fax:
Practice Address - Street 1:17900 NW 5TH ST STE 102
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2809
Practice Address - Country:US
Practice Address - Phone:954-367-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL396112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic