Provider Demographics
NPI:1437134640
Name:JANTZ, BRETT R (PT)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:R
Last Name:JANTZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11216 EL CAPITAN WAY
Mailing Address - Street 2:
Mailing Address - City:BALLICO
Mailing Address - State:CA
Mailing Address - Zip Code:95303-9738
Mailing Address - Country:US
Mailing Address - Phone:209-678-4584
Mailing Address - Fax:
Practice Address - Street 1:11216 EL CAPITAN WAY
Practice Address - Street 2:
Practice Address - City:BALLICO
Practice Address - State:CA
Practice Address - Zip Code:95303-9738
Practice Address - Country:US
Practice Address - Phone:209-678-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT237490Medicare ID - Type Unspecified