Provider Demographics
NPI:1457950321
Name:VAN WINKLE, JARED (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:VAN WINKLE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 E 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-2254
Mailing Address - Country:US
Mailing Address - Phone:605-857-0043
Mailing Address - Fax:
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist