Provider Demographics
NPI:1336352079
Name:JACK, THEA ELIZABETH (MPT,PCS)
Entity Type:Individual
Prefix:MRS
First Name:THEA
Middle Name:ELIZABETH
Last Name:JACK
Suffix:
Gender:F
Credentials:MPT,PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MALL CT STE B
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3691
Mailing Address - Country:US
Mailing Address - Phone:912-713-0277
Mailing Address - Fax:888-429-3741
Practice Address - Street 1:10 MALL CT STE B
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3691
Practice Address - Country:US
Practice Address - Phone:912-713-0277
Practice Address - Fax:888-429-3741
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0094792251P0200X
NJQA010952002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA739344620CMedicaid