Provider Demographics
NPI:1184747461
Name:HERRICK, JEFFREY P (PT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:P
Last Name:HERRICK
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 1:50 POINT DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-9608
Mailing Address - Country:US
Mailing Address - Phone:304-257-9383
Mailing Address - Fax:
Practice Address - Street 1:35 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1727
Practice Address - Country:US
Practice Address - Phone:304-257-2606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9420169000Medicaid