Individual
MRS. THEA ELIZABETH JACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MPT,PCS
Contact information
Practice address
10 MALL CT STE B, SAVANNAH, GA 31406-3691
(912) 713-0277
(888) 429-3741
Mailing address
10 MALL CT STE B, SAVANNAH, GA 31406-3691
(912) 713-0277
(888) 429-3741
Taxonomy
Speciality
Code
Description
License number
State
2251P0200X
Pediatric Physical Therapist
Primary
PT009479
GA
2251P0200X
Pediatric Physical Therapist
QA01095200
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
739344620C
—
GA
Enumeration date
05/08/2007
Last updated
07/31/2020
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