Provider Demographics
NPI:1427863463
Name:HARLEY, JACK STEPHEN (PTA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:STEPHEN
Last Name:HARLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 PARK RD
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1019
Mailing Address - Country:US
Mailing Address - Phone:419-689-0192
Mailing Address - Fax:
Practice Address - Street 1:1451 GAMBIER RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9112
Practice Address - Country:US
Practice Address - Phone:740-397-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA008206225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant