Healthcare Provider Details

I. General information

NPI: 1932713286
Provider Name (Legal Business Name): JACK DYLAN NEAL WEBSTER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15543 N REEMS RD STE 133
SURPRISE AZ
85374-9582
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY STE 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 623-975-5374
  • Fax:
Mailing address:
  • Phone: 217-808-1913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number31447
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: