Provider Demographics
NPI:1710953302
Name:PENNOCK, JEFFREY JOSEPH (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:PENNOCK
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:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:TUCKERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08087-5500
Mailing Address - Country:US
Mailing Address - Phone:609-294-1484
Mailing Address - Fax:
Practice Address - Street 1:798 ROUTE 539 STE 2
Practice Address - Street 2:
Practice Address - City:LITTLE EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08087-4203
Practice Address - Country:US
Practice Address - Phone:609-294-4720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00043300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist