Provider Demographics
NPI:1073952867
Name:VANKLOMPENBURG, JEREMY (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:VANKLOMPENBURG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216-8237
Mailing Address - Country:US
Mailing Address - Phone:605-541-1140
Mailing Address - Fax:605-541-0109
Practice Address - Street 1:9219 WATER ST
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MI
Practice Address - Zip Code:49437-9206
Practice Address - Country:US
Practice Address - Phone:231-893-6655
Practice Address - Fax:231-525-0144
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist