Basic Information
| Provider Information | |||||||||
| NPI: | 1578119905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERENCAK | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | DPT, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 LEXINGTON GREEN LN | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327711013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073223442 | ||||||||
| FaxNumber: | 4073228404 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 W BASS ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347415011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076244688 | ||||||||
| FaxNumber: | 4079104223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2019 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT35043 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.