Provider Demographics
NPI:1407879265
Name:SHANO, JACK M (RPT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:M
Last Name:SHANO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23067 VENTURA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1150
Mailing Address - Country:US
Mailing Address - Phone:818-223-9985
Mailing Address - Fax:818-223-9986
Practice Address - Street 1:23067 VENTURA BLVD STE A
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1150
Practice Address - Country:US
Practice Address - Phone:818-223-9985
Practice Address - Fax:818-223-9986
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT3035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT3035OtherLICENSE NUMBER
CAPT3035OtherLICENSE NUMBER