Provider Demographics
NPI:1518525542
Name:ROBERTS, JACK A (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:ROBERTS
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 1:1300 W SAM HOUSTON PKWY S STE 300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2453
Mailing Address - Country:US
Mailing Address - Phone:713-297-6792
Mailing Address - Fax:713-430-4041
Practice Address - Street 1:4621 W PARK BLVD STE 102
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-2318
Practice Address - Country:US
Practice Address - Phone:972-985-1776
Practice Address - Fax:972-985-6088
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1318000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist