Provider Demographics
NPI:1659848109
Name:QUESENBERRY, JACK AMBERS
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:AMBERS
Last Name:QUESENBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 E STUART DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2407
Mailing Address - Country:US
Mailing Address - Phone:276-238-8118
Mailing Address - Fax:762-238-8119
Practice Address - Street 1:969 E STUART DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2407
Practice Address - Country:US
Practice Address - Phone:276-238-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305212219OtherLICENSE