Provider Demographics
NPI:1245581404
Name:JERTBERG, LAWRENCE (LMT)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:JERTBERG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16824 NW 174TH TER
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-4731
Mailing Address - Country:US
Mailing Address - Phone:386-569-7801
Mailing Address - Fax:386-462-4062
Practice Address - Street 1:16824 NW 174TH TER
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-4731
Practice Address - Country:US
Practice Address - Phone:386-569-7801
Practice Address - Fax:386-462-4062
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA62326225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist