Provider Demographics
NPI:1295243301
Name:PONTIUS, JEREK CHARLES (ATC)
Entity type:Individual
Prefix:MR
First Name:JEREK
Middle Name:CHARLES
Last Name:PONTIUS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 N GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-2914
Mailing Address - Country:US
Mailing Address - Phone:815-990-5395
Mailing Address - Fax:
Practice Address - Street 1:627 N GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-2914
Practice Address - Country:US
Practice Address - Phone:815-990-5395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer