Provider Demographics
NPI:1790458495
Name:ALBERT, JACK RAYMOND
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:RAYMOND
Last Name:ALBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 PHYSICAL EDUCATION BUILDING
Mailing Address - Street 2:EASTERN WASHINGTON UNIVERSITY
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-2476
Mailing Address - Country:US
Mailing Address - Phone:509-359-6399
Mailing Address - Fax:
Practice Address - Street 1:207 PHYSICAL EDUCATION BUILDING
Practice Address - Street 2:EASTERN WASHINGTON UNIVERSITY
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-2476
Practice Address - Country:US
Practice Address - Phone:509-359-6399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty