Provider Demographics
NPI:1598076671
Name:JACK, ALEXANDRA LAINE (DPT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LAINE
Last Name:JACK
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 1:1977 DEWAR DR STE J
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5757
Mailing Address - Country:US
Mailing Address - Phone:307-382-3228
Mailing Address - Fax:307-382-6886
Practice Address - Street 1:1977 DEWAR DR STE J
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5757
Practice Address - Country:US
Practice Address - Phone:307-382-3228
Practice Address - Fax:307-382-6886
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist