Healthcare Provider Details

I. General information

NPI: 1376811612
Provider Name (Legal Business Name): JESSE ROLAND GEFROH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHIEF EDDIE HOFFMAN HIGHWAY
BETHEL AK
99559
US

IV. Provider business mailing address

PO BOX 287
BETHEL AK
99559-0287
US

V. Phone/Fax

Practice location:
  • Phone: 907-543-6300
  • Fax: 907-543-6366
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2359
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: