Provider Demographics
NPI:1669418489
Name:ELLERTSON, JACK W (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:W
Last Name:ELLERTSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-2986
Mailing Address - Country:US
Mailing Address - Phone:717-264-6211
Mailing Address - Fax:717-264-9816
Practice Address - Street 1:1035 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-2986
Practice Address - Country:US
Practice Address - Phone:717-264-6211
Practice Address - Fax:717-264-9816
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPTO16235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAELI1783757OtherBLUE SHIELD
PWELI1783757OtherFEDERAL BLUE SHIELD
PA50056652OtherCROSS
PWELI1783757OtherFEDERAL BLUE SHIELD