Provider Demographics
NPI:1558678110
Name:EBERT, JIM (OT)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:EBERT
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 OLDEN CT
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-1441
Mailing Address - Country:US
Mailing Address - Phone:732-740-9682
Mailing Address - Fax:
Practice Address - Street 1:7 OLDEN CT
Practice Address - Street 2:
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-1441
Practice Address - Country:US
Practice Address - Phone:732-740-9682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006813172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker