Provider Demographics
NPI:1063519726
Name:VAN DER BEEK, JARED (PT)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:VAN DER BEEK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1A WAINWRIGHT PL
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-5034
Mailing Address - Country:US
Mailing Address - Phone:415-763-5523
Mailing Address - Fax:
Practice Address - Street 1:1801 BUSH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5239
Practice Address - Country:US
Practice Address - Phone:415-763-5523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA009772225100000X
PAPT016150225100000X
CAAC 13995171100000X
CA33779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA096974UV9Medicare ID - Type Unspecified
NJ071914RYYMedicare ID - Type Unspecified