Provider Demographics
NPI:1013027507
Name:ERDAL, JEAN E (PT)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:E
Last Name:ERDAL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2063 HOVINGTON CIR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7065
Mailing Address - Country:US
Mailing Address - Phone:904-220-5693
Mailing Address - Fax:
Practice Address - Street 1:2063 HOVINGTON CIR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7065
Practice Address - Country:US
Practice Address - Phone:904-220-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0003674225100000X
MO01072225100000X
WI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40407800Medicaid
WI40407800Medicaid
WI004883450Medicare ID - Type Unspecified