Provider Demographics
NPI:1275657355
Name:STAGGE, JACK M (PT, OCS,)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:STAGGE
Suffix:
Gender:M
Credentials:PT, OCS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 GRANT RD
Mailing Address - Street 2:STE B27
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-7715
Mailing Address - Country:US
Mailing Address - Phone:509-884-2992
Mailing Address - Fax:
Practice Address - Street 1:230 GRANT ROAD, SUITE B27
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802
Practice Address - Country:US
Practice Address - Phone:509-884-1437
Practice Address - Fax:509-884-2811
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7052665Medicaid
WAGAB00888Medicare ID - Type Unspecified
WAR11386Medicare UPIN