Provider Demographics
NPI:1437178969
Name:PHILBRICK, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:PHILBRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 3RD ST SE
Mailing Address - Street 2:STE 210
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1519 3RD ST SE
Practice Address - Street 2:STE 210
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3742
Practice Address - Country:US
Practice Address - Phone:253-445-1844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017083208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology