Provider Demographics
NPI:1790182632
Name:BARRACK, JACOB A (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:A
Last Name:BARRACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-6007
Mailing Address - Country:US
Mailing Address - Phone:760-726-9660
Mailing Address - Fax:760-726-8865
Practice Address - Street 1:115 MAIN ST
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6007
Practice Address - Country:US
Practice Address - Phone:760-726-9660
Practice Address - Fax:760-726-8865
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41928225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic