Provider Demographics
NPI:1093357626
Name:VAN HORN, JACK ALEXANDER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALEXANDER
Last Name:VAN HORN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 WESTMINSTER DR
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1981
Mailing Address - Country:US
Mailing Address - Phone:937-726-3430
Mailing Address - Fax:
Practice Address - Street 1:935 N CASSADY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-2283
Practice Address - Country:US
Practice Address - Phone:614-252-4987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist