Provider Demographics
NPI:1760502173
Name:VAN ZWOL, JEROEN P (PT)
Entity Type:Individual
Prefix:PROF
First Name:JEROEN
Middle Name:P
Last Name:VAN ZWOL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 N SPRING GARDEN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0900
Mailing Address - Country:US
Mailing Address - Phone:386-734-2592
Mailing Address - Fax:386-734-1773
Practice Address - Street 1:929 N SPRING GARDEN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0900
Practice Address - Country:US
Practice Address - Phone:386-734-2592
Practice Address - Fax:386-734-1773
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8706OtherBCBS #
FLY8706ZMedicare ID - Type UnspecifiedMEDICARE #