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Individual
MR. JACK W ELLERTSON
Active
Individual
MR. JACK W ELLERTSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHYSICAL THERAPIST
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PTO16235
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50056652
CROSS
PA
01
—
ELI1783757
BLUE SHIELD
PA
01
—
ELI1783757
FEDERAL BLUE SHIELD
PW
Enumeration date
06/21/2006
Last updated
07/09/2012
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