Provider Demographics
NPI:1619166964
Name:WALSH, JAKE BARTHOLOMEW (DPT)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:BARTHOLOMEW
Last Name:WALSH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3905 WARING RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4405
Mailing Address - Country:US
Mailing Address - Phone:760-477-1350
Mailing Address - Fax:760-754-6785
Practice Address - Street 1:6121 PASEO DEL NORTE STE 200
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1161
Practice Address - Country:US
Practice Address - Phone:760-448-9050
Practice Address - Fax:760-754-6785
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGOtherMEDICARE