Provider Demographics
NPI:1013113778
Name:VERHEES, JACK (PT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:VERHEES
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 1:4904 S CLYDE MORRIS BLVD
Mailing Address - Street 2:STE D2
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4170
Mailing Address - Country:US
Mailing Address - Phone:386-898-0908
Mailing Address - Fax:386-898-0242
Practice Address - Street 1:4904 S CLYDE MORRIS BLVD
Practice Address - Street 2:STE D2
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4170
Practice Address - Country:US
Practice Address - Phone:386-898-0908
Practice Address - Fax:386-898-0242
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT9087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1869541OtherMAIL HNADLERS GROUP
FL5687755OtherMAIL HANDLERSFIRST HEALTH
FLY923LOtherBCBS FACILITY PO
FL1720155997OtherGROUP NPI
FL2381853OtherAETNA GROUP #
FLY923DOtherBCBS FACILITY OC
FL1196963OtherAETNA PPO #
FLY926BOtherBCBS FACILITY OB
FLY0894UOtherBCBS #
FLU5774ZMedicare ID - Type Unspecified
FL1720155997OtherGROUP NPI
FLQ52839Medicare UPIN
FLK1325Medicare ID - Type UnspecifiedGROUP MEDICARE #