Provider Demographics
NPI:1528675741
Name:DERSTINE, JACOB (DPT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:DERSTINE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 SALFORDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HARLEYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19438-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3250 STATE RD
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1624
Practice Address - Country:US
Practice Address - Phone:215-257-2751
Practice Address - Fax:215-257-7390
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist