Provider Demographics
NPI:1760265565
Name:JACKSON, GABRIELLE C ETCHEGARAY (DPT)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:C ETCHEGARAY
Last Name:JACKSON
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 1:505 N EUCLID ST STE 680
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5509
Mailing Address - Country:US
Mailing Address - Phone:714-780-0010
Mailing Address - Fax:714-912-8640
Practice Address - Street 1:505 N EUCLID ST STE 680
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5509
Practice Address - Country:US
Practice Address - Phone:714-780-0010
Practice Address - Fax:714-912-8640
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist