Provider Demographics
NPI:1295033645
Name:BRAY, JACK OLIVER (RRT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:OLIVER
Last Name:BRAY
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 10TH ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2217
Mailing Address - Country:US
Mailing Address - Phone:619-423-2429
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31046227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered