Provider Demographics
NPI:1417115940
Name:EBBEN, JACQUELINE (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:EBBEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2964 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1593
Mailing Address - Country:US
Mailing Address - Phone:248-393-0788
Mailing Address - Fax:
Practice Address - Street 1:1185 S ADAMS RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-7101
Practice Address - Country:US
Practice Address - Phone:248-988-8098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-31
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist