Provider Demographics
NPI:1336112739
Name:HURT, JERALD L (PT)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:L
Last Name:HURT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:HURT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1810 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-7904
Mailing Address - Country:US
Mailing Address - Phone:409-763-7025
Mailing Address - Fax:409-763-8648
Practice Address - Street 1:1810 TREMONT ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-7904
Practice Address - Country:US
Practice Address - Phone:409-763-7025
Practice Address - Fax:409-763-8648
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1015105225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760684651OtherTAX ID OF GROUP
TX1015105OtherPT LICENSE #
TX8T4268OtherBCBS PROVIDER #
TX00107SMedicare ID - Type UnspecifiedGROUP # MY # ASSIGNED TO
TX8T4268OtherBCBS PROVIDER #