Provider Demographics
NPI:1700420221
Name:JACK, ANNE THERESE (PT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:THERESE
Last Name:JACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4255 NORTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2811
Mailing Address - Country:US
Mailing Address - Phone:216-292-9700
Mailing Address - Fax:216-378-4613
Practice Address - Street 1:24211 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4211
Practice Address - Country:US
Practice Address - Phone:440-250-2520
Practice Address - Fax:440-250-2530
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist