Provider Demographics
NPI:1619552874
Name:BARBER, JACK (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BARBER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 HIGHWAY 7 APT 603
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2253
Mailing Address - Country:US
Mailing Address - Phone:262-705-9014
Mailing Address - Fax:
Practice Address - Street 1:4810 HIGHWAY 7 APT 603
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2253
Practice Address - Country:US
Practice Address - Phone:262-705-9014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15180-24225100000X
MN12068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist