MEDICARE: MR. JEFFREY JOSEPH PENNOCK PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QB00043300	NJ

General Provider Information

NPI Number	:	1710953302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY JOSEPH PENNOCK PTA

Provider Business Mailing Address
First Line	:	PO BOX 1500
Second Line	:
City	:	TUCKERTON
State	:	NJ
Zip	:	08087-5500
Country	:	US
Telephone Number	:	609-294-1484
Fax Number	:

Provider Business Practice Location Address
First Line	:	798 ROUTE 539 STE 2
Second Line	:
City	:	LITTLE EGG HARBOR TWP
State	:	NJ
Zip	:	08087-4203
Country	:	US
Telephone Number	:	609-294-4720
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	03/21/2008

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