Provider Demographics
NPI:1629203633
Name:VAN BOCKEL, JAY MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:MICHAEL
Last Name:VAN BOCKEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7643 MERASTONE LN NE
Mailing Address - Street 2:A-203
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8834
Mailing Address - Country:US
Mailing Address - Phone:337-258-9870
Mailing Address - Fax:
Practice Address - Street 1:2701 CLARE AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3313
Practice Address - Country:US
Practice Address - Phone:360-377-3951
Practice Address - Fax:360-377-5443
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160046920208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation