Healthcare Provider Details

I. General information

NPI: 1972599819
Provider Name (Legal Business Name): JAY HERDSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 UNIVERSITY BLVD SUITE 120
ELLICOTT CITY MD
21043-6074
US

IV. Provider business mailing address

6011 UNIVERSITY BLVD SUITE 120
ELLICOTT CITY MD
21043-6074
US

V. Phone/Fax

Practice location:
  • Phone: 410-203-0391
  • Fax: 410-203-2707
Mailing address:
  • Phone: 410-203-0391
  • Fax: 410-203-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number19964
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number19964
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19964
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: