Provider Demographics
NPI:1972599819
Name:HERDSON, JAY (PT)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:HERDSON
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 1:6011 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6074
Mailing Address - Country:US
Mailing Address - Phone:410-203-0391
Mailing Address - Fax:410-203-2707
Practice Address - Street 1:6011 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6074
Practice Address - Country:US
Practice Address - Phone:410-203-0391
Practice Address - Fax:410-203-2707
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD199642251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD075353000Medicaid
MD293466OtherMAMSI
MD6545-0007OtherBLUE CHOICE
MDK666-M572Medicare UPIN