Provider Demographics
NPI:1083919278
Name:JACK, DANIEL L JR (PT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:JACK
Suffix:JR
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 1:1185 TO LANI DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-5361
Mailing Address - Country:US
Mailing Address - Phone:404-298-7708
Mailing Address - Fax:
Practice Address - Street 1:1185 TO LANI DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-5361
Practice Address - Country:US
Practice Address - Phone:404-298-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist