Provider Demographics
NPI:1669020798
Name:MACKEY, MARRYJANE ESTAMO (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:MARRYJANE
Middle Name:ESTAMO
Last Name:MACKEY
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:MARRYJANE
Other - Middle Name:ESTAMO
Other - Last Name:LUCHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:3128 S BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-7682
Mailing Address - Country:US
Mailing Address - Phone:216-325-2329
Mailing Address - Fax:
Practice Address - Street 1:3128 S BRIDGE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-7682
Practice Address - Country:US
Practice Address - Phone:216-325-2329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist