Sol Johanna Jaque, PTA – Physical Therapy Assistant

Key facts

NPI: 1750153615
Entity type: Individual (NPI type 1)
Primary specialty: Physical Therapy Assistant 225200000X
License: PTA-014722 (AZ)
Practice address: 191 Swanson Ave Ste 102
Lake Havasu City, AZ 86403-6699
Phone: (928) 855-7880
NPI assigned: Oct 24, 2023
Sex: Female
Sole proprietor: No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Agave Physical Therapy LLC Physical Therapy Clinic/Center · Lake Havasu City, AZ · NPI 1720521040

NPD

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No

State licenses

License	State	Type	Specialty
PTA-014722	AZ	MD	Physical Therapy Assistant

Practice roles

Organization	Specialty	Status	New patients
Agave Physical Therapy LLC		Current since Oct 29, 2023	Accepting new patients

Locations

191 Swanson Ave
Ste 102
Lk Havasu Cty, AZ 86403
Phone (928) 855-7880

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Physical Therapy Assistant	225200000X	PTA-014722	AZ	Yes

Addresses

Primary practice location

191 Swanson Ave Ste 102
Lake Havasu City, AZ 86403-6699

Mailing address

191 Swanson Ave Ste 102
Lake Havasu City, AZ 86403-6699

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Oct 24, 2023.

{
    "created_epoch": "1698105600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1698105600000",
    "number": "1750153615",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "191 SWANSON AVE STE 102",
            "city": "LAKE HAVASU CITY",
            "state": "AZ",
            "postal_code": "864036699"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "191 SWANSON AVE STE 102",
            "city": "LAKE HAVASU CITY",
            "state": "AZ",
            "postal_code": "864036699",
            "telephone_number": "928-855-7880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JAQUE",
        "first_name": "SOL",
        "middle_name": "JOHANNA",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2023-10-24",
        "last_updated": "2023-10-24",
        "certification_date": "2023-10-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "AZ",
            "license": "PTA-014722",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Havasu City, AZ

All providers in Lake Havasu City, AZ · Physical Therapy Assistant in Arizona

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 24, 2023. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.