Provider Demographics
NPI:1043353410
Name:DERKSEN, JELTSJE WILLEMIEN (PT)
Entity Type:Individual
Prefix:
First Name:JELTSJE
Middle Name:WILLEMIEN
Last Name:DERKSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 LINKSIDE CT E
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-4386
Mailing Address - Country:US
Mailing Address - Phone:904-982-2193
Mailing Address - Fax:
Practice Address - Street 1:4131 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 17
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4326
Practice Address - Country:US
Practice Address - Phone:904-722-1515
Practice Address - Fax:904-722-1517
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889647000Medicaid