Provider Demographics
NPI:1447510524
Name:FRY, JACK P (DPT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:P
Last Name:FRY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 MOUNTAIN VILLAGE DR APT D
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-2157
Mailing Address - Country:US
Mailing Address - Phone:435-230-4307
Mailing Address - Fax:
Practice Address - Street 1:157 LEWIS ST
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-7699
Practice Address - Country:US
Practice Address - Phone:907-488-4978
Practice Address - Fax:907-488-4976
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist