Provider Demographics
NPI:1811160674
Name:DE LOS SANTOS, JOREL (PT)
Entity type:Individual
Prefix:
First Name:JOREL
Middle Name:
Last Name:DE LOS SANTOS
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 1:105 AZALEA AVE N
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537-3421
Mailing Address - Country:US
Mailing Address - Phone:912-496-4345
Mailing Address - Fax:
Practice Address - Street 1:501 N OCEAN ST
Practice Address - Street 2:APARTMENT 608
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3148
Practice Address - Country:US
Practice Address - Phone:904-354-6276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11101225100000X
GAGA006263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT11101OtherSTATE
GAPT006263OtherSTATE