Provider Demographics
NPI:1578808648
Name:TKACHUK, JESSICA ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:TKACHUK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 POTTER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-4826
Mailing Address - Country:US
Mailing Address - Phone:857-413-7600
Mailing Address - Fax:
Practice Address - Street 1:2030 ADDISON ST
Practice Address - Street 2:101
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1158
Practice Address - Country:US
Practice Address - Phone:510-644-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist