Provider Demographics
NPI:1932302007
Name:HANSON, JACK EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:HANSON
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 1:1120 15TH ST STE BI1056
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-3813
Mailing Address - Fax:
Practice Address - Street 1:1220 W WHEELER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:706-721-5222
Practice Address - Fax:706-721-1459
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist